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Case Services

Case Services - Application, Eligibility, Planning

Form Name Action Form Owner Revision Date Notes
Application - Spanish Print
 Angela Fujan 07/01/2024
Application - English Print
Data Entry 		Angela Fujan 07/01/2024 Updated per Angela 11/19/2024 Updated gender 10/20/23 Updated CAP phone number. 5/16/2023 Removed Sources & Services pages 4-30-2019 Updated with TBI stuff on 12-20-2021
Communication Assessment - English Print
Data Entry 		Angela Fujan 01/24/2023
Job Planning Factors & Job Planning Discussion Order
 Angela Fujan 10/26/2021
IL Assessment-Barriers to Employment Print
 Carla Lasley 07/31/2008
IL Assessment-Household, Relocation, Cleaning Print
 Carla Lasley
IL Assessment-Menu Planning/Prep, Laundry/Clothing Care, Daycare Print
 Carla Lasley 07/31/2008
IL Assessment-Rehab Engineering & Assistive Tech Print
 Carla Lasley 07/31/2008
IL Assessment-School Needs Print
 Carla Lasley 07/31/2008
IL Assessment-Transportation, Health & Hygiene Print
 Carla Lasley 07/31/2008
IL Assessment-Work-Site Needs/Accommodations Print
 Carla Lasley 07/31/2008
Physical Capacities Print
Data Entry 		Angela Fujan 02/28/2014
Job Readiness Factors & Initial Meeting - A Guide for Staff Order
 Angela Fujan 10/26/2021
VR Psychological Narrative Report Guidelines Print
 Angela Fujan 08/31/2006
Functional Capacities Checklist Print
Order
Data Entry 		Angela Fujan 04/10/2019
Impairments Checklist Print
Order
 Angela Fujan 08/09/2019
Nebraska VR ABI Interview Data Entry Keri Bennett 05/24/2022
Career Planning Preferences - English Print
Data Entry 		Angela Fujan 01/01/2016
(TWE) Trial Work Experience Agreement Data Entry Kristi Berst 02/23/2022
Order of Selection (OOS) Questions & Answers Print
 Angela Fujan 05/08/2018
Information and Referral (I & R) to Other Programs Print
Data Entry 		Paige Rose 07/12/2022 Used for CCIR appointments, and clients on the wait list during order of selection. I and R, I & R
Guide for Approval of Eligibility and Priority Groups Print
 Angela Fujan 11/30/2017
Order of Selection (OOS) Fact Sheet Print
 Angela Fujan 10/03/2022
Order of Selection Communication to VR staff on process for working with DDD while all categories are closed Print
 Lindy Foley 06/04/2018
Order of Selection communication to VR staff on process for working with BH Regions while all categories are closed Print
 Lindy Foley 06/04/2018
Q & A on Employment Plans Print
 Carla Lasley 06/19/2018 Questions and answers are from a 6-19-18 Videoconference attended by VR staff.
Template, Background, & Instructions for Completion of Employment Plan (I/DD) Print
Data Entry 		Carla Lasley
Template, Background, Instructions for BH Employment Plan Print
 Carla Lasley 07/09/2018
Order of Selection Update for BH SE Milestones Print
 Carla Lasley 07/18/2018 updated per DHHS
VR Referral Form - English Print
Data Entry 		Angela Fujan 10/20/2023
Key VR Time Frames Print
 Angela Fujan 01/02/2019
Signing of VR Documents chart Print
 Carla Lasley 04/02/2019
Initial Meeting Questions Print
 Angela Fujan 08/01/2019
Impediment Questions Print
 Angela Fujan 04/04/2019
Summary of Initial Meeting Print
Data Entry 		Angela Fujan 04/04/2019
Summary of Initial Meeting-Spanish Print
Data Entry 		Angela Fujan 04/04/2019
Information and Referral (I & R) to Other Programs - Spanish Print
Data Entry 		Paige Rose 07/12/2022 I and R, I & R,
Order of Selection Job Retention Questions Print
Data Entry 		Angela Fujan 03/31/2019
Order of Selection (OOS) Fact Sheet Spanish Print
 Angela Fujan 10/03/2022
VR Process Chart Angela Fujan 10/26/2021
Initial Meeting to Next Step Guide Print
 Angela Fujan 03/31/2021
Clients Removed from Wait List Who are Working Print
 Paige Rose 02/25/2020
Client User ID Password Letter Print
 Cathy Callaway 07/15/2021
On-Line Access to Pay Stub - English Print
 Cathy Callaway 10/29/2024
On-line Access to Pay Stub - Spanish Print
 Cathy Callaway 10/29/2024
Career Planning Preferences - Spanish Print
Data Entry 		Angela Fujan 04/15/2020
VR Referral Form - Spanish Print
Data Entry 		Angela Fujan 10/20/2023
OOS Upgrading Priority Group Letter - English Print
 Angela Fujan 08/04/2021
AbilityOne Process Data Entry Paige Rose 04/01/2022
OOS Upgrading Priority Group Letter - Spanish Print
 Angela Fujan 08/27/2021
Progressive Employment Model Mary Matusiak 03/31/2022
Substance Use Disorders- VR Desk Reference Print
 Angela Fujan 11/18/2022 Rehabilitation Research and Training Center on Substance Abuse, Disability and Employment
Communication Assessment - Spanish Print
Data Entry 		Angela Fujan 01/24/2023
List of Background Checks Carla Lasley 01/05/2024
Functional Cognitive Assessment Referral Data Entry Keri Bennett 10/29/2024

Case Services - Case, Caseload Management

Form Name Action Form Owner Revision Date Notes
Action Planner Order
 Angela Fujan 08/31/2011
Appointment Reminder Postcard Order
 Sarah Chapin 05/20/2014
Assignment Purchases-Medicare Print
 Cathy Callaway Must open this document in Excel
Assignment Purchases-Third Party Print
 Cathy Callaway This document must be opened in Excel
Blank Memo Post Card Order
 Sarah Chapin
Case File Order List Print
 Angela Fujan 06/04/1919
Client Reimbursement Print
 Cathy Callaway 04/30/2019
Acceptance Agreement Form (Equipment Agreement) Print
Data Entry 		Mary Matusiak 02/28/2021
High Cost Request Print
Data Entry 		Angela Fujan 09/24/2019
Next Steps - English Order
 Angela Fujan 11/30/2010
Proof of Purchase Print
Data Entry 		Cathy Callaway 04/30/2019
Suicide Call Print
Data Entry 		Holly Enriquez 02/28/2009
Provider Invoice Print
Data Entry 		Cathy Callaway 02/28/2013
Next Steps- Spanish Print
 Angela Fujan 11/30/2015
Purchase of Goods and Services Print
 Angela Fujan 05/01/2017
Key VR Time Frames Print
 Angela Fujan 01/02/2019
Exit Status Decision Tree Print
 Paige Rose
Electronic Case File Categories/Attachment Types Cathy Callaway 04/01/2024
A Guide for Supporting Individuals With Developmental Disabilities In The Workplace Print
 Cathy Callaway 11/01/2010 This was content saved from the old VRIS>
Case File Request for Information Print
Data Entry 		Cathy Callaway 04/13/2023
Medicaid Spreadsheet (No Insurance) Data Entry Amy Hancock
Medicaid Spreadsheet (With Insurance) Data Entry Cathy Callaway 03/31/2025
Case Review - Compliance (Draft) Holly Enriquez 06/30/2024
Case Review - Quality (Draft) Holly Enriquez 06/30/2024

Case Services - IPE

Form Name Action Form Owner Revision Date Notes
Corrective Action Plan Print
Data Entry 		Cathy Callaway 04/30/2019
IPE Guide Print
 Angela Fujan 08/30/2019
Assessment for Competitive Integrated Employment Determination Checklist Print
Data Entry 		Kristi Berst 04/01/2024
Individualized Plan for Employment (IPE) - English Data Entry Cathy Callaway 12/03/2024
IPE Services Data Entry Cathy Callaway 07/01/2024
Assessment Services Cathy Callaway 04/08/2022
Assessment Supports Cathy Callaway 07/01/2023
Individualized Plan for Employment (IPE) - Spanish Cathy Callaway 12/03/2024
State VR SSA Coordinators Carla Lasley 07/07/2022
Discovery Activity: Work Values - English Data Entry Angela Fujan 05/11/2023
Discovery Activity: Work Values - Spanish Print
Data Entry 		Angela Fujan 05/11/2023
Discovery Activity: Work Preferences - English Print
Data Entry 		Angela Fujan 05/11/2023
Discovery Activity: Work Preferences - Spanish Print
Data Entry 		Angela Fujan 05/11/2023
Discovery Activity: Work Interests - Spanish Print
Data Entry 		Angela Fujan 05/11/2023
Discovery Activity: Work Interests - English Angela Fujan 05/11/2023
Discovery Activity: Work Considerations - English Print
Data Entry 		Angela Fujan 05/11/2023
Discovery Activity: Work Considerations - Spanish Print
Data Entry 		Angela Fujan 05/11/2023
Discovery Activity: Non-Paid Work Experiences - Spanish Print
Data Entry 		Angela Fujan 05/11/2023
Discovery Activity: Non-Paid Work Experiences - English Angela Fujan 05/11/2023
Discovery Activity: Make Sure - English Print
Data Entry 		Angela Fujan 05/11/2023
Discovery Activity: Make Sure - Spanish Print
Data Entry 		Angela Fujan 05/11/2023
Discovery Activity: Job Skills - Spanish Print
Data Entry 		Angela Fujan 05/11/2023
Discovery Activity: Job Skills - English Angela Fujan 05/11/2023
Discovery Activity: Family Support Network - English Print
Data Entry 		Angela Fujan 05/11/2023
Discovery Activity: Family Support Network - Spanish Print
Data Entry 		Angela Fujan 05/11/2023
Discovery Activity: Application for Employment - English Print
Data Entry 		Angela Fujan 05/11/2023
Discovery Activity: Application for Employment - Spanish Print
Data Entry 		Angela Fujan 05/11/2023

Case Services - Letters

Form Name Action Form Owner Revision Date Notes
15 Day Letter - English Print
 Angela Fujan 02/14/2020
Office Director Letter Print
 Angela Fujan 10/07/2022
Successful Outcome Letter (Non SSA) in English Print
 Angela Fujan 10/07/2022
Termination Letter for Non SSA Recipients in English Print
 Angela Fujan 10/07/2022
Welcome Letter with Link to Orientation Video-Constant Contact Sarah Chapin 07/10/2024
Schedule A Certification Letter for VR Staff Print
 Mary Matusiak 10/01/2018
Pre-Employment Transition Services Work Based Learning Letter-Paid Print
Data Entry 		Lupe Stevens 08/30/2017
Pre-Employment Transition Services Work Based Learning Letter-Unpaid Print
Data Entry 		Lupe Stevens 08/30/2017
Order of Selection Retention Letter Print
 Angela Fujan 11/19/2020 Example of Retention letter sent out from State Office
OOS Off Wait List Letter - English Print
 Angela Fujan 02/25/2020 Example of Off Wait List letter sent out by State Office
Orientation Welcome Letter-Word version Print
 Sarah Chapin 12/14/2017
Eligibility Letter - English Angela Fujan 07/01/2024 Example of Adult waiting list letter sent out by State Office
OOS Upgrading Priority Group Letter - English Print
 Angela Fujan 08/04/2021
Contact Letter - English Print
 Angela Fujan 04/17/2019
Successful Outcome Letter (Non SSA) in Spanish Print
 Angela Fujan 10/07/2022
Termination Letter for SSA Recipients in English Print
 Carla Lasley 10/07/2022
Successful Outcome Letter (SS beneficiaries) in English Print
 Carla Lasley 10/07/2022
Termination Letter for SSA Recipients in Spanish Print
 Carla Lasley 10/07/2022
Successful Outcome Letter (SS beneficiaries) in Spanish Print
 Carla Lasley 10/07/2022
OOS Upgrading Priority Group Letter - Spanish Print
 Angela Fujan 08/27/2021
OJT Letter Print
Data Entry 		Mary Matusiak 01/12/2022
Contact Letter - Spanish Print
 Angela Fujan 04/25/2022
15 Day Letter - Spanish Angela Fujan 05/11/2022
Termination Letter for Non SSA Recipients in Spanish Angela Fujan 10/12/2022
Eligibility Letter - Spanish Print
 Angela Fujan 05/07/2020
OOS Off Wait List Letter - Spanish Print
 Angela Fujan 11/18/2022

Case Services - OJE, OJT, Payroll, Placement

Form Name Action Form Owner Revision Date Notes
Direct Deposit Enrollment Print
Data Entry 		Cinda Wacker 07/31/2013
Job Facts Guide Print
Order
 Mary Matusiak 05/31/2014 Job Facts Guide is available as a fillable pdf.
Job Search Agreement and Consent - English Print
Order
Data Entry 		Mary Matusiak 03/16/2023
Job Search Agreement and Consent - Spanish Print
Data Entry 		Mary Matusiak 03/16/2023
Job Seeking Skills Training Application Print
Data Entry 		Mary Matusiak
Job Seeking Skills Training Booklet - English Order
 Mary Matusiak 12/01/2017
I-9 Checklist Print
 Holly Enriquez
I-9 Form & Information Print
 Amy Hancock 03/06/2024 Amy Hancock provided this update on 10-31-23
W-4 Employee's Withholding Allowance Certificate Print
Data Entry 		Holly Enriquez 01/02/2025
Weekly Job Search Record Print
Order
Data Entry 		Mary Matusiak
Work Opportunity Tax Credits - 9061 Individual Characteristics - English Print
 Mary Matusiak
Work Opportunity Tax Credits - 9061 Individual Characteristics - Spanish Print
 Mary Matusiak
Work Opportunity Tax Credits - 8850 - Pre-Screening Notice & Certification Request - English Print
 Mary Matusiak
Work Opportunity Tax Credits - 8850 - Pre-Screening Notice & Certification Request - Spanish Print
 Mary Matusiak
Work Opportunity Tax Credits - 8850 - Pre-Screening Notice & Certification Request Instructions Print
 Mary Matusiak
On-the-Job Report Print
Data Entry 		Kristi Berst 07/01/2020 Replaces the OJT Training Progress Report and OJE Evaluation Report
Volunteer/Non-Paid Accident Coverage Holly Enriquez 08/07/2024 This form confirms that the State of Nebraska Vocational Rehabilitation has insurance in place for all registered volunteers and participants as outlined.
Request for Certificate of Self-Insurance Print
 Holly Enriquez 07/01/2024
Focus Card Enrollment Form Print
Data Entry 		Amy Hancock 07/05/2023
Request Temporary Access Print
 Holly Enriquez 06/06/2022
Time Conversion Chart Print
 Cathy Callaway
W-4N Employee’s Nebraska Withholding Allowance Certificate Print
Data Entry 		Holly Enriquez 07/05/2023
2024 OJE/TWE/WBLE Bi-weekly Payroll Schedule Print
 Melysa Johnson 12/13/2023
OJE/TWE Checklist Print
Data Entry 		Kristi Berst 02/25/2022
OJE/TWE Timesheet Print
Data Entry 		Kristi Berst 01/12/2022
OJE/TWE Consent Print
Data Entry 		Kristi Berst 01/12/2022
Optional Invoice for Providers WSST/Job Coaching 7/23 Amy Hancock 11/20/2023
Pearls of Placement Reference Guide Mary Matusiak 01/24/2024
Employment Success Skills Mary Matusiak 10/09/2024
2025 OJE/TWE/WBLE Bi-weekly Payroll Schedule Melysa Johnson 12/11/2024

Case Services - Post Secondary

Form Name Action Form Owner Revision Date Notes
Budget Worksheet-Post-Secondary Print
 Angela Fujan 05/31/2006
Budget Worksheet-Education Financial Aid Print
 Angela Fujan 03/02/2016
Financial Aid Budget Information Print
 Angela Fujan 02/03/2011
Post Secondary Training Justification - Word doc Print
Data Entry 		Angela Fujan 09/30/2010
Post Secondary Training Justification - PDF Print
Data Entry 		Angela Fujan 09/30/2010
Student Financial Aid Report (SFAR-E) Data Entry Angela Fujan 08/14/2024
VR Financial Aid Data Entry Angela Fujan 11/10/2022
Informational Interview Questionnaire Data Entry Paige Rose 11/20/2018

Case Services - Release, Consent, Referral

Form Name Action Form Owner Revision Date Notes
NE VR Sign Language Interpreting Request Print
Order
 Vicki Steinhaur-Campbell 05/05/2016
VR Referral Form - English Print
Data Entry 		Angela Fujan 10/20/2023
Release of Information English Print
Data Entry 		Angela Fujan 02/13/2024
Request for Medical Information - English Print
Data Entry 		Angela Fujan 04/01/2019
Emancipated Minor Form Print
 Carla Lasley 04/02/2019
Self Employment Feasibility Referral Form Print
Data Entry 		Julie Shively 05/23/2022
Agrability Referral Print
Data Entry 		Angela Fujan 03/31/2014
ATP/VR Referral Print
Data Entry 		Nancy Noha 03/27/2024
BP/DHHS Authorization for the Disclosure of Protected Health Information Print
Data Entry 		Carla Lasley 01/22/2020
Authorization for Exchange of Information-Multi Agency Release Print
 Carla Lasley 04/30/2019
Benefits Orientation/Referral for Benefits Services Print
Data Entry 		Carla Lasley 04/12/2024
Maximus: Notification To Take Ticket Out of Assignment Print
Data Entry 		Carla Lasley 09/30/2012
Mediation Referral Print
 Angela Fujan 04/30/2019
Service & Device Application - English Print
 Nancy Noha 10/20/2023 Multi-Agency Form
Vocational Evaluation Referral Print
 Paige Rose 12/08/2022
Video & Media Information Release (Client) Print
Data Entry 		Sarah Chapin 04/29/2025 Release of Information, Media Release, Consent for Media
Pre-Employment Transition Services Consent & Information Release - English Print
Data Entry 		Lupe Stevens 05/16/2023
Pre-Employment Transition Services Consent & Information Release - Spanish Print
Data Entry 		Lupe Stevens 05/16/2023
Section 511: Refusal of Pre-Employment Transition Services (While still in High School) Data Entry Paige Rose 11/30/2020
ATP-CPAP Facility Assessment Referral Form Print
Data Entry 		Nancy Noha 07/18/2017 For BAM and CPAP staff use with businesses
Pre-ETS Job Exploration Referral Data Entry Paige Rose 01/24/2023
Benefits Provider Choice or Declination - English Print
 Carla Lasley 08/23/2024
BP/DHHS Authorization for the Disclosure of Protected Health Information-Spanish Print
Data Entry 		Carla Lasley 01/22/2020
VR Referral Form - English Print
Data Entry 		Angela Fujan 10/20/2023
Title II: Social Security Disability Insurance Work Incentives Guide 2025 - English Print
 Carla Lasley 01/01/2025
Title XVI: Supplemental Security Income Work Incentives Guide 2025 - English Print
 Carla Lasley 01/01/2025
Background Screen Release of Information (Disclosure and Authorization Form) Print
 Mary Matusiak
Pre-Employment Transition Services Release of Information English Print
Data Entry 		Lupe Stevens 04/29/2020
Release of Information Spanish Print
Data Entry 		Angela Fujan 02/13/2024
Request for Medical Information - Spanish Print
Data Entry 		Angela Fujan 04/01/2019
VR Referral Form - Spanish Print
Data Entry 		Angela Fujan 10/20/2023
Pre-Employment Transition Services Release of Information Spanish Print
Data Entry 		Lupe Stevens 04/30/2020
Benefits Provider Choice or Declination - Spanish Print
Data Entry 		Carla Lasley 08/23/2024
Title XVI: Supplemental Security Income Work Incentives Guide 2025 - Spanish Print
 Carla Lasley 01/01/2025
Service & Device Application - Spanish Print
 Nancy Noha 10/20/2023
BP/SSA 3288 Consent for Release of Information - General English Data Entry Carla Lasley 11/10/2021
BP/SSA 3288 Consent for Release of Information - General Spanish Print
Order
 Carla Lasley 11/10/2021
VR/SSA 3288 Consent for Release of Information - General English Print
Data Entry 		Carla Lasley 11/10/2021
VR/SSA 3288 Consent for Release of Information - General Spanish Print
Data Entry 		Carla Lasley 11/10/2021
Title II: Social Security Disability Insurance Work Incentives Guide 2024 - English Data Entry Carla Lasley 12/26/2023
Title II: Social Security Disability Insurance Work Incentives Guide 2024 - Spanish Print
Data Entry 		Carla Lasley 12/26/2023
Title XVI: Supplemental Security Income Work Incentives Guide 2024 - English Print
 Carla Lasley 03/25/2024
Title XVI: Supplemental Security Income Work Incentives Guide 2024 - Spanish Print
 Carla Lasley 03/25/2024
Concurrent Work Incentives Guide 2025 - English Print
 Carla Lasley 01/01/2025
Concurrent Work Incentives Guide 2025 - Spanish Print
 Carla Lasley 01/01/2025
Guide for Nebraska VR Staff Requesting Information from NE Department of Correctional Services Holly Enriquez 08/25/2022
Title II: Social Security Disability Insurance Work Incentives Guide 2025 - Spanish Print
 Carla Lasley 01/01/2025
Concurrent Work Incentives Guide 2024 - English Carla Lasley 03/25/2024
Concurrent Work Incentives Guide 2024 - Spanish Carla Lasley 03/25/2024
Pre-ETS Benefits Orientation - Discussion Referral Lindsay Brown 04/02/2025

CPAP 2.0

Form Name Action Form Owner Revision Date Notes
CPAP 2.0 Individualized Business Plan (IBP) Print
Data Entry 		Mary Kunes-Neary 08/16/2022

Section 511

Form Name Action Form Owner Revision Date Notes
Section 511: Refusal of Pre-Employment Transition Services (While still in High School) Data Entry Paige Rose 11/30/2020
Section 511: Refusal to Participate - English Data Entry Paige Rose 01/27/2023
Section 511: Documentation Checklist for Adults (age 25 and older) Data Entry Paige Rose 02/24/2020
Section 511: Documentation Checklist for Youth (Age 24 and younger) Print
Data Entry 		Paige Rose 02/24/2020
Information and Referral (I & R) to Other Programs Print
Data Entry 		Paige Rose 07/12/2022 Used for CCIR appointments, and clients on the wait list during order of selection. I and R, I & R
Information and Referral (I & R) to Other Programs - Spanish Print
Data Entry 		Paige Rose 07/12/2022 I and R, I & R,
Section 511: CCIR Case Review Checklist Print
Data Entry 		Paige Rose 01/24/2023
Section 511: Refusal to Participate - Spanish Data Entry Paige Rose 01/27/2023

Self Employment-Planning

Form Name Action Form Owner Revision Date Notes
Self Employment Discussion Questionnaire-Data Entry Print
Data Entry 		Julie Shively 03/24/2021 Use this Word version to allow for expanding data entry. Tab between fields.
Self Employment Rates & Hourly Estimates Print
 Mary Matusiak 05/25/2023
Self Employment Personal Finance Worksheet Print
Data Entry 		Julie Shively 02/07/2017
Self Employment-Advantages Print
 Julie Shively 03/01/2017
Self-Employment - Green Flags/Red Flags Print
 Julie Shively 12/10/2021
Self Employment Feasibility Referral Form Print
Data Entry 		Julie Shively 05/23/2022
Self Employment Process Chart Print
 Julie Shively 01/26/2018
Supported Self-Employment Guidance Print
 Mary Matusiak 05/23/2018
Sources & Uses of Funds Print
Data Entry 		Julie Shively 04/09/2021
Viability Referral Data Entry Angela Fujan 06/14/2021 Download form to open in Word.

Supported/Customized Employment

Form Name Action Form Owner Revision Date Notes
VR Profile for Supported or Customized Employment Data Entry Paige Rose 04/30/2019
Supported Self-Employment Guidance Print
 Mary Matusiak 05/23/2018
ABI/Autism SE Supplemental Questionnaire Print
Data Entry 		Carla Lasley 11/30/2018
AbilityOne Process Data Entry Paige Rose 04/01/2022
Supported and Customized Employment Referral Data Entry DJ Plautz 07/01/2023 New form as of 7/1/2023/
Supported and Customized Employment Plan for Job Development - Outcome Report & Invoice Data Entry DJ Plautz 09/01/2023 New as of 7/1/2023
Supported and Customized Employment Job Search and Placement - Outcome Report & Invoice Data Entry DJ Plautz 09/01/2023
Supported and Customized Employment Monthly Report Data Entry DJ Plautz 07/01/2023
Supported and Customized Employment Job Stability Report Data Entry DJ Plautz 07/01/2023 Active 7/1/2023
Supported and Customized Employment Extended Services for Youth Report & Invoice Data Entry DJ Plautz 09/20/2023 Active on 7/1/2023, updated on 9/29.
Supported and Customized Employment Job Coaching/Job Support Report & Invoice Data Entry DJ Plautz 12/13/2024 Active on 7/1/2023. Updated in 9/25. Updated 12/13/24
Supported and Customized Employment Verification of Employee Hours Worked Data Entry DJ Plautz 09/01/2023
Supported and Customized Employment - Side by Side Referral Decision Guide DJ Plautz 07/01/2023 Provided by the Vocational Rehabilitation Technical Assistance Center for Quality Employment (VRTAC-QE) . tacqe.com
Supported and Customized Employment Fiscal Chart Print
 DJ Plautz 11/22/2023
Supported and Customized Employment Provider Handbook Print
 DJ Plautz 11/22/2023
Supported/Customized Employment Payment Schedule DJ Plautz 07/01/2024

Pre-Employment Transition Services

Work Based Learning

Form Name Action Form Owner Revision Date Notes
Pre-Employment Transition Services Consent for a Paid Work Based Learning Experience (14-15 y.o.) Print
Data Entry 		Lupe Stevens 04/30/2019
Pre-Employment Transition Services Consent for a Paid Work Based Learning Experience (16+ y.o.) Print
Data Entry 		Lupe Stevens 04/30/2019
Pre-Employment Transition Services Work-Based Learning Experience Information Lindsay Brown 05/05/2022
Work-Based Learning Experience (WBLE) Timesheet Print
Data Entry 		Lindsay Brown 06/13/2023 work-based
Pre-Employment Transition Services Work-Based Learning Experience Report Print
Data Entry 		Lupe Stevens 06/20/2019
Pre-Employment Transition Services Work-Based Learning Experience (WBLE) Checklist Print
Data Entry 		Lupe Stevens 08/29/2023
Pre-Employment Transition Services Consent for a Non-paid Work Based Learning Experience Print
Data Entry 		Lupe Stevens 04/30/2019
Pre-Employment Transition Services Consent for a Paid Work Based Learning Experience (14-15 y.o.) Spanish Print
Data Entry 		Lupe Stevens 04/30/2019
Pre-Employment Transition Services Consent for a Paid Work Based Learning Experience (16+ y.o.) Spanish Print
Data Entry 		Lupe Stevens 04/30/2019
Pre-Employment Transition Services Work-Based Learning Experience Information Spanish Lindsay Brown 05/04/2022
Pre-Employment Transition Services Consent & Information Release - English Print
Data Entry 		Lupe Stevens 05/16/2023
Pre-Employment Transition Services Consent & Information Release - Spanish Print
Data Entry 		Lupe Stevens 05/16/2023
Pre-Employment Transition Services Consent for Non-paid Work Based Learning Experience Spanish Print
Data Entry 		Lupe Stevens 04/30/2019
Nebraska VR/SPED Inter-Departmental Agreement Print
 Lindy Foley 08/22/2018 Inter-departmental agreement between Nebraska VR and the Office of Special Education (SPED)
Signing of VR Documents chart Print
 Carla Lasley 04/02/2019
Pre-Employment Transition Services Release of Information English Print
Data Entry 		Lupe Stevens 04/29/2020
Pre-Employment Transition Services Release of Information Spanish Print
Data Entry 		Lupe Stevens 04/30/2020
Transition Services Partnership Planner Lupe Stevens 08/16/2021
W-4 Employee's Withholding Allowance Certificate Print
Data Entry 		Holly Enriquez 01/02/2025
I-9 Form & Information Print
 Amy Hancock 03/06/2024 Amy Hancock provided this update on 10-31-23
W-4N Employee’s Nebraska Withholding Allowance Certificate Print
Data Entry 		Holly Enriquez 07/05/2023
On-Line Access to Pay Stub - English Print
 Cathy Callaway 10/29/2024
Class Work Site Observation Checklist Print
Data Entry 		Paige Rose 04/02/2021
2024 OJE/TWE/WBLE Bi-weekly Payroll Schedule Print
 Melysa Johnson 12/13/2023
Optional Invoice for Providers WSST/Job Coaching 7/23 Amy Hancock 11/20/2023
2025 OJE/TWE/WBLE Bi-weekly Payroll Schedule Melysa Johnson 12/11/2024
Pre-ETS Letter Non Participation - English Lindsay Brown 01/28/2025
Pre-ETS Letter Non Participation - Spanish Lindsay Brown 01/28/2025
Pre-ETS Letter Termination after Graduation - English Lindsay Brown 01/28/2025
Pre-ETS Letter Termination after Graduation - Spanish Lindsay Brown 01/28/2025
Pre-ETS Letter Change of Contact - English Lindsay Brown 01/28/2025
Pre-ETS Letter Change of Contact - Spanish Lindsay Brown 01/28/2025
Pre-ETS Letter Welcome - English Lindsay Brown 01/28/2025
Pre-ETS Letter Welcome - Spanish Lindsay Brown 01/28/2025

Administrative

Administrative - NDE

Form Name Action Form Owner Revision Date Notes
Volunteer/Unpaid Intern Print
 Holly Enriquez This form is housed on Inside NDE.
Contracts, Letter Contracts, Purchasing Procedures Cathy Callaway
Direct Deposit Enrollment Print
Data Entry 		Cinda Wacker 07/31/2013
Horizontal Wage Progression Holly Enriquez Contact NDE HR for this form.
I-9 Checklist Print
 Holly Enriquez
I-9 Form & Information Print
 Amy Hancock 03/06/2024 Amy Hancock provided this update on 10-31-23
Merit Stipend Request Holly Enriquez Contact NDE HR for this form
Work Schedule Print
 Holly Enriquez
Focus Card Enrollment Form Print
Data Entry 		Amy Hancock 07/05/2023
ADA Guidance Print
 Holly Enriquez 02/24/2017
Work Opportunity Tax Credits - 8850 - Pre-Screening Notice & Certification Request Instructions Print
 Mary Matusiak
2024 OJE/TWE/WBLE Bi-weekly Payroll Schedule Print
 Melysa Johnson 12/13/2023
2025 OJE/TWE/WBLE Bi-weekly Payroll Schedule Melysa Johnson 12/11/2024

Administrative - Nebraska VR

Form Name Action Form Owner Revision Date Notes
Confidentiality Agreement Print
 Holly Enriquez 07/27/2021
Incident/Accident/Injury Report for Clients & Applicants Print
Data Entry 		Holly Enriquez 02/08/2023
Direct Purchase Authorization (DPA) Print
Data Entry 		Cathy Callaway
Employee Roster Information Print
Data Entry 		Holly Enriquez 05/03/2017
Position Information Sheet Associate Print
Data Entry 		Holly Enriquez 10/25/2019
Position Information Sheet Service/Rehab Specialists Print
Data Entry 		Holly Enriquez 10/25/2019
Supported Employment Case Review DJ Plautz 07/01/2024
Service Agreement Data Entry Carla Lasley 02/20/2025
Training Request Print
Data Entry 		Ken Cuevas 02/18/2020
TSB Log Print
 Melysa Johnson
Video & Media Information Release (Client) Print
Data Entry 		Sarah Chapin 04/29/2025 Release of Information, Media Release, Consent for Media
Video Conference Participant List Print
 Paige Rose 11/09/2018
I-9 Checklist Print
 Holly Enriquez
State Vehicle Waiver - VR English and Spanish Print
 Holly Enriquez 06/04/2019 English and Spanish waiver
VR Vendor Office Listing Print
 Cathy Callaway 12/31/2012
Suicide Call Form Print
Data Entry 		Holly Enriquez 12/16/2015
Code of Conduct Print
Data Entry 		Angela Fujan 02/01/2021
Summary of Case Review Findings Print
Data Entry 		Angela Fujan 01/13/2020
Transition Partnership Planning Form Data Entry Lupe Stevens 08/17/2021 Link to web form for the Transition Services Partnership Planner - Guide for Educators
Training Plan Data Entry Ken Cuevas 09/19/2018
18/23 Month Assessment Action Plan Print
Data Entry 		Holly Enriquez 09/05/2018
Order of Selection (OOS) Talking Points Print
Data Entry 		Lindy Foley 05/03/2018
Nebraska VR/SPED Inter-Departmental Agreement Print
 Lindy Foley 08/22/2018 Inter-departmental agreement between Nebraska VR and the Office of Special Education (SPED)
NCBVI and Nebraska VR MOU Print
 Angela Fujan
Continuity of Operations Plan (COOP) for COVID-19 Print
 Lindy Foley 08/26/2021
Nebraska VR Question and Answers Continuity of Operations Plan (COOP)- COVID 19 Print
 Lindy Foley 04/01/2021
Fax Log Print
Data Entry 		Tibor Moldovan 05/01/2020
2024 OJE/TWE/WBLE Bi-weekly Payroll Schedule Print
 Melysa Johnson 12/13/2023
External Agency/Business Partner Media Release Data Entry Mary Matusiak 03/16/2022
Request Temporary Access Print
 Holly Enriquez 06/06/2022
Compliance Review (Download Word Document) Cathy Callaway 06/12/2024
Quality Review (Download Word Document) Cathy Callaway 06/12/2024
2025 OJE/TWE/WBLE Bi-weekly Payroll Schedule Melysa Johnson 12/11/2024

Administrative - State of Nebraska

Form Name Action Form Owner Revision Date Notes
Voter Registration Form English Print
Data Entry 		Holly Enriquez 06/24/2024
Tax Exempt Form (Form 13) Print
 Cathy Callaway 02/21/2025 Office Listing is included with the form
W-4 Employee's Withholding Allowance Certificate Print
Data Entry 		Holly Enriquez 01/02/2025
W-9 & ACH Enrollment Print
Data Entry 		Cinda Wacker
CSI Exception Request Print
Data Entry 		Holly Enriquez 09/23/2024
Voter Registration Form Spanish Print
Data Entry 		Holly Enriquez 06/24/2024
W-4N Employee’s Nebraska Withholding Allowance Certificate Print
Data Entry 		Holly Enriquez 07/05/2023
Voter Registration Disclaimer Print
 Holly Enriquez 04/01/2020
Voter Registration Disclaimer-Spanish Print
 Holly Enriquez 04/14/2020
Records Transfer Sheet Print
 Holly Enriquez 04/06/2023

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