Where your future begins

Search Forms


   List All Forms    New/Updated Forms

Case Services

Case Services - Application, Eligibility, Planning

Form Name Action Form Owner Revision Date Notes
Application - Spanish Print
 Angela Fujan 2024-07-01
Application - English Print
Data Entry 		Angela Fujan 2024-07-01 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 2023-01-24
Job Planning Factors & Job Planning Discussion Order
 Angela Fujan 2021-10-26
Physical Capacities Print
Data Entry 		Angela Fujan 2014-02-28
Job Readiness Factors & Initial Meeting - A Guide for Staff Order
 Angela Fujan 2021-10-26
VR Psychological Narrative Report Guidelines Print
 Angela Fujan 2006-08-31
Functional Capacities Checklist Print
Order
Data Entry 		Angela Fujan 2019-04-10
Impairments Checklist Print
Order
 Angela Fujan 2019-08-09
Nebraska VR ABI Interview Data Entry Keri Bennett 2026-05-11
Career Planning Preferences - English Print
Data Entry 		Angela Fujan 2016-01-01
(TWE) Trial Work Experience Plan Data Entry Kristi Berst 2025-06-05
Order of Selection (OOS) Questions & Answers Print
 Angela Fujan 2018-05-08
Information and Referral (I & R) to Other Programs Print
Data Entry 		Angela Fujan 2022-07-12 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 2017-11-30
Order of Selection (OOS) Fact Sheet Print
 Angela Fujan 2022-10-03
Order of Selection Communication to VR staff on process for working with DDD while all categories are closed Print
 Lindy Foley 2018-06-04
Order of Selection communication to VR staff on process for working with BH Regions while all categories are closed Print
 Lindy Foley 2018-06-04
VR Referral Form - English Print
Data Entry 		Angela Fujan 2023-10-20
Key VR Timeframes Print
 Angela Fujan 2025-08-21
Signing of VR Documents chart Print
 Carla Lasley 2019-04-02
Initial Meeting Questions Print
 Angela Fujan 2019-08-01
Impediment Questions Print
 Angela Fujan 2023-05-04
Summary of Initial Meeting Print
Data Entry 		Angela Fujan 2019-04-04
Summary of Initial Meeting-Spanish Print
Data Entry 		Angela Fujan 2019-04-04
Information and Referral (I & R) to Other Programs - Spanish Print
Data Entry 		Angela Fujan 2022-07-12 I and R, I & R,
Order of Selection Job Retention Questions Print
Data Entry 		Angela Fujan 2019-03-31
Order of Selection (OOS) Fact Sheet Spanish Print
 Angela Fujan 2022-10-03
VR Process Chart Angela Fujan 2021-10-26
Initial Meeting to Next Step Guide Print
 Angela Fujan 2021-03-31
Client User ID Password Letter Print
 Cathy Callaway 2021-07-15
On-Line Access to Pay Stub - English Print
 Cathy Callaway 2026-01-07 Approved by Kaylee Huenink
On-line Access to Pay Stub - Spanish Print
 Cathy Callaway 2026-01-07 Approved by Kaylee Huenink
Career Planning Preferences - Spanish Print
Data Entry 		Angela Fujan 2020-04-15
VR Referral Form - Spanish Print
Data Entry 		Angela Fujan 2023-10-20
OOS Upgrading Priority Group Letter - English Print
 Angela Fujan 2021-08-04
AbilityOne Process Data Entry Kristi Berst 2022-04-01
OOS Upgrading Priority Group Letter - Spanish Print
 Angela Fujan 2021-08-27
Progressive Employment Model Michael Enriquez 2022-03-31
Substance Use Disorders- VR Desk Reference Print
 Angela Fujan 2022-11-18 Rehabilitation Research and Training Center on Substance Abuse, Disability and Employment
Communication Assessment - Spanish Print
Data Entry 		Angela Fujan 2023-01-24
List of Background Checks Carla Lasley 2024-01-05
Functional Cognitive Assessment Referral Data Entry Keri Bennett 2026-01-29
OJE Letter - Paid Kristi Berst 2025-06-05
OJE Letter - Unpaid Kristi Berst 2025-06-05
What to Expect During Nebraska VR ABI Interview Print
 Keri Bennett 2025-11-24

Case Services - Case, Caseload Management

Form Name Action Form Owner Revision Date Notes
Action Planner Order
 Angela Fujan 2011-08-31
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
Case File Order List Print
 Angela Fujan 2019-06-04
Client Reimbursement Print
 Cathy Callaway 2019-04-30
Acceptance Agreement Form (Equipment Agreement) Print
Data Entry 		Michael Enriquez 2021-02-28
High Cost Request Print
Data Entry 		Angela Fujan 2019-09-24
Next Steps - English Order
 Angela Fujan 2010-11-30
Proof of Purchase Print
Data Entry 		Cathy Callaway 2019-04-30
Suicide Call Print
Data Entry 		Holly Enriquez 2009-02-28
Provider Invoice Print
Data Entry 		Cathy Callaway 2026-02-26
Next Steps- Spanish Print
 Angela Fujan 2015-11-30
Purchase of Goods and Services Print
 Angela Fujan 2017-05-01
Key VR Timeframes Print
 Angela Fujan 2025-08-21
Exit Status Decision Tree Print
 Kristi Berst 2025-06-05
Electronic Case File Categories/Attachment Types Cathy Callaway 2025-06-05
Case File Request for Information Print
Data Entry 		Cathy Callaway 2023-04-13
Medicaid Spreadsheet (No Insurance) Data Entry Amy Hancock
Medicaid Spreadsheet (With Insurance) Data Entry Cathy Callaway 2025-03-31
Case Review - Compliance (Draft) Holly Enriquez 2024-06-30
Case Review - Quality (Draft) Holly Enriquez 2024-06-30

Case Services - IPE

Form Name Action Form Owner Revision Date Notes
Corrective Action Plan Print
Data Entry 		Cathy Callaway 2019-04-30
IPE Amendment of Job Goal at Outcome/Termination of Service - English Angela Fujan 2022-04-13 Subject: From termination Sarah, Please remove from service the following forms as they will no longer be used: • IPE Amendment of Job Goal at Outcome/Termination of Service (English & Spanish) • IPE – Termination of Service (English & Spanish) Thanks, Angela Fujan Program Director Office of Nebraska VR
IPE Amendment of Job Goal at Outcome/Termination of Service - Spanish Angela Fujan 2022-04-13 Subject: From termination Sarah, Please remove from service the following forms as they will no longer be used: • IPE Amendment of Job Goal at Outcome/Termination of Service (English & Spanish) • IPE – Termination of Service (English & Spanish) Thanks, Angela Fujan Program Director Office of Nebraska VR
IPE Guide Print
 Angela Fujan 2019-08-30
Assessment for Competitive Integrated Employment Determination Checklist Print
Data Entry 		Kristi Berst 2024-04-01
Individualized Plan for Employment (IPE) - English Data Entry Cathy Callaway 2024-12-03
IPE Services Data Entry Cathy Callaway 2024-07-01
Assessment Services Cathy Callaway 2022-04-08
Assessment Supports Cathy Callaway 2023-07-01
Individualized Plan for Employment (IPE) - Spanish Cathy Callaway 2024-12-03
Discovery Activity: Work Values - English Data Entry Angela Fujan 2023-05-11
Discovery Activity: Work Values - Spanish Print
Data Entry 		Angela Fujan 2023-05-11
Discovery Activity: Work Preferences - English Print
Data Entry 		Angela Fujan 2023-05-11
Discovery Activity: Work Preferences - Spanish Print
Data Entry 		Angela Fujan 2023-05-11
Discovery Activity: Work Interests - Spanish Print
Data Entry 		Angela Fujan 2023-05-11
Discovery Activity: Work Interests - English Angela Fujan 2023-05-11
Discovery Activity: Work Considerations - English Print
Data Entry 		Angela Fujan 2023-05-11
Discovery Activity: Work Considerations - Spanish Print
Data Entry 		Angela Fujan 2023-05-11
Discovery Activity: Non-Paid Work Experiences - Spanish Print
Data Entry 		Angela Fujan 2023-05-11
Discovery Activity: Non-Paid Work Experiences - English Angela Fujan 2023-05-11
Discovery Activity: Make Sure - English Print
Data Entry 		Angela Fujan 2023-05-11
Discovery Activity: Make Sure - Spanish Print
Data Entry 		Angela Fujan 2023-05-11
Discovery Activity: Job Skills - Spanish Print
Data Entry 		Angela Fujan 2023-05-11
Discovery Activity: Job Skills - English Angela Fujan 2023-05-11
Discovery Activity: Family Support Network - English Print
Data Entry 		Angela Fujan 2023-05-11
Discovery Activity: Family Support Network - Spanish Print
Data Entry 		Angela Fujan 2023-05-11
Discovery Activity: Application for Employment - English Print
Data Entry 		Angela Fujan 2023-05-11
Discovery Activity: Application for Employment - Spanish Print
Data Entry 		Angela Fujan 2023-05-11

Case Services - Letters

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

Case Services - OJE, OJT, Payroll, Placement

Form Name Action Form Owner Revision Date Notes
Direct Deposit Enrollment Print
Data Entry 		Cinda Wacker 2013-07-31
Job Facts Guide Print
Order
 Michael Enriquez 2014-05-31 Job Facts Guide is available as a fillable pdf.
Job Search Agreement and Consent - English Print
Order
Data Entry 		Michael Enriquez 2023-03-16
Job Search Agreement and Consent - Spanish Print
Data Entry 		Michael Enriquez 2023-03-16
Job Seeking Skills Training Application Print
Data Entry 		Michael Enriquez
Job Seeking Skills Training Booklet - English Order
 Michael Enriquez 2017-12-01
I-9 Checklist Print
 Holly Enriquez
I-9 Form & Information Print
 Amy Hancock 2024-03-06 Amy Hancock provided this update on 10-31-23
W-4 Employee's Withholding Allowance Certificate Print
Data Entry 		Holly Enriquez 2026-01-07
Weekly Job Search Record Print
Order
Data Entry 		Michael Enriquez
Work Opportunity Tax Credits - 9061 Individual Characteristics - English Print
 Michael Enriquez
Work Opportunity Tax Credits - 9061 Individual Characteristics - Spanish Print
 Michael Enriquez
Work Opportunity Tax Credits - 8850 - Pre-Screening Notice & Certification Request - English Print
 Michael Enriquez
Work Opportunity Tax Credits - 8850 - Pre-Screening Notice & Certification Request - Spanish Print
 Michael Enriquez
Work Opportunity Tax Credits - 8850 - Pre-Screening Notice & Certification Request Instructions Print
 Michael Enriquez
On-the-Job Report Print
Data Entry 		Kristi Berst 2025-06-30 Replaces the OJT Training Progress Report and OJE Evaluation Report
Volunteer/Non-Paid Accident Coverage Holly Enriquez 2025-07-07 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 Holly Enriquez 2025-07-01
Focus Card Enrollment Form Print
Data Entry 		Amy Hancock 2023-07-05
Request Temporary Access Print
 Holly Enriquez 2022-06-06
Time Conversion Chart Print
 Cathy Callaway
W-4N Employee’s Nebraska Withholding Allowance Certificate Print
Data Entry 		Holly Enriquez 2023-07-05
2026 OJE/TWE/WBLE Bi-weekly Payroll Schedule Print
 Melysa Johnson 2025-12-16
OJE/TWE Checklist Print
Data Entry 		Kristi Berst 2022-02-25
OJE/TWE Timesheet Print
Data Entry 		Kristi Berst 2022-01-12
OJE/TWE Consent Print
Data Entry 		Kristi Berst 2022-01-12
Optional Invoice for Providers WSST/Job Coaching 7/23 Amy Hancock 2023-11-20
Pearls of Placement Reference Guide Michael Enriquez 2024-01-24
Employment Success Skills Michael Enriquez 2024-10-09
2025 OJE/TWE/WBLE Bi-weekly Payroll Schedule Melysa Johnson 2024-12-11

Case Services - Post Secondary

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

Case Services - Release, Consent, Referral

Form Name Action Form Owner Revision Date Notes
NE VR Sign Language Interpreting Request Print
Order
 Vicki Steinhaur-Campbell 2016-05-05
VR Referral Form - English Print
Data Entry 		Angela Fujan 2023-10-20
Release of Information English Print
Data Entry 		Angela Fujan 2024-02-13
Request for Medical Information - English Print
Data Entry 		Angela Fujan 2019-04-01
Emancipated Minor Form Print
 Carla Lasley 2019-04-02
Self Employment Feasibility Referral Form Print
Data Entry 		Julie Shively 2022-05-23
Agrability Referral Print
Data Entry 		Angela Fujan 2014-03-31
ATP/VR Referral Print
Data Entry 		Nancy Noha 2024-03-27
BP/DHHS Authorization for the Disclosure of Protected Health Information Data Entry Carla Lasley 2026-03-24
Authorization for Exchange of Information-Multi Agency Release Print
 Carla Lasley 2019-04-30
Benefits Orientation/Referral for Benefits Services Print
Data Entry 		Carla Lasley 2024-04-12
Mediation Referral Print
 Angela Fujan 2019-04-30
Service & Device Application - English Print
 Nancy Noha 2023-10-20 Multi-Agency Form
Vocational Evaluation Referral Print
 Kristi Berst 2022-12-08
Video and Media Information Release for Clients Print
Data Entry 		Sarah Chapin 2025-04-29 Release of Information, Media Release, Consent for Media
Pre-Employment Transition Services Consent & Information Release - English Print
Data Entry 		Lupe Stevens 2023-05-16
Pre-Employment Transition Services Consent & Information Release - Spanish Print
Data Entry 		Lupe Stevens 2023-05-16
Section 511: Refusal of Pre-Employment Transition Services (While still in High School) Data Entry DJ Plautz 2020-11-30
ATP-CPAP Facility Assessment Referral Form Print
Data Entry 		Nancy Noha 2017-07-18 For BAM and CPAP staff use with businesses
Pre-ETS Job Exploration Referral Data Entry Lupe Stevens 2023-01-24
Benefits Provider Choice or Declination - English Print
 Carla Lasley 2026-03-26
BP/DHHS Authorization for the Disclosure of Protected Health Information-Spanish Print
Data Entry 		Carla Lasley 2026-03-24
VR Referral Form - English Print
Data Entry 		Angela Fujan 2023-10-20
Title II: Social Security Disability Insurance Work Incentives Guide 2025 - English Print
 Carla Lasley 2025-01-01
Title XVI: Supplemental Security Income Work Incentives Guide 2025 - English Print
 Carla Lasley 2025-01-01
Background Screen Release of Information (Disclosure and Authorization Form) Print
 Michael Enriquez
Pre-Employment Transition Services Release of Information English Print
Data Entry 		Lupe Stevens 2020-04-29
Release of Information Spanish Print
Data Entry 		Angela Fujan 2024-02-13
Request for Medical Information - Spanish Print
Data Entry 		Angela Fujan 2019-04-01
VR Referral Form - Spanish Print
Data Entry 		Angela Fujan 2023-10-20
Pre-Employment Transition Services Release of Information Spanish Print
Data Entry 		Lupe Stevens 2020-04-30
Benefits Provider Choice or Declination - Spanish Print
Data Entry 		Carla Lasley 2026-03-26
Title XVI: Supplemental Security Income Work Incentives Guide 2025 - Spanish Print
 Carla Lasley 2025-01-01
Service & Device Application - Spanish Print
 Nancy Noha 2023-10-20
BP/SSA 3288 Consent for Release of Information - General English Data Entry Carla Lasley 2026-03-19
BP/SSA 3288 Consent for Release of Information - General Spanish Data Entry Carla Lasley 2026-03-19
VR/SSA 3288 Consent for Release of Information - General English Print
Data Entry 		Carla Lasley 2021-11-10
VR/SSA 3288 Consent for Release of Information - General Spanish Print
Data Entry 		Carla Lasley 2021-11-10
Title II: Social Security Disability Insurance Work Incentives Guide 2026 - English Data Entry Carla Lasley 2025-11-26
Title II: Social Security Disability Insurance Work Incentives Guide 2026 - Spanish Print
Data Entry 		Carla Lasley 2025-11-26
Title XVI: Supplemental Security Income Work Incentives Guide 2026 - English Print
 Carla Lasley 2026-03-04
Title XVI: Supplemental Security Income Work Incentives Guide 2026 - Spanish Print
 Carla Lasley 2026-02-04
Concurrent Work Incentives Guide 2025 - English Print
 Carla Lasley 2025-01-01
Concurrent Work Incentives Guide 2025 - Spanish Print
 Carla Lasley 2025-01-01
Guide for Nebraska VR Staff Requesting Information from NE Department of Correctional Services Holly Enriquez 2022-08-25
Title II: Social Security Disability Insurance Work Incentives Guide 2025 - Spanish Print
 Carla Lasley 2025-01-01
Concurrent Work Incentives Guide 2026 - English Carla Lasley 2026-03-04
Concurrent Work Incentives Guide 2026 - Spanish Carla Lasley 2025-11-26
Pre-ETS Benefits Orientation - Discussion Referral Lindsay Brown 2025-10-30

CPAP 2.0

Form Name Action Form Owner Revision Date Notes
CPAP 2.0 Individualized Business Plan (IBP) Print
Data Entry 		Ami Stubben-Goetsch 2022-08-16

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 DJ Plautz 2020-11-30
Section 511: Refusal to Participate - English Data Entry DJ Plautz 2023-01-27
Section 511: Documentation Checklist for Adults (age 25 and older) Data Entry DJ Plautz 2020-02-24
Section 511: Documentation Checklist for Youth (Age 24 and younger) Print
Data Entry 		DJ Plautz 2020-02-24
Information and Referral (I & R) to Other Programs Print
Data Entry 		Angela Fujan 2022-07-12 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 		Angela Fujan 2022-07-12 I and R, I & R,
Section 511: CCIR Case Review Checklist Print
Data Entry 		DJ Plautz 2023-01-24
Section 511: Refusal to Participate - Spanish Data Entry DJ Plautz 2023-01-27

Self Employment-Planning

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

Supported/Customized Employment

Form Name Action Form Owner Revision Date Notes
Supported Self-Employment Guidance Print
 Michael Enriquez 2018-05-23
ABI/Autism SE Supplemental Questionnaire Print
Data Entry 		Carla Lasley 2018-11-30
AbilityOne Process Data Entry Kristi Berst 2022-04-01
Supported and Customized Employment Referral Data Entry DJ Plautz 2023-07-01 New form as of 7/1/2023/
Supported and Customized Employment Plan for Job Development - Outcome Report & Invoice Data Entry DJ Plautz 2025-07-01 New as of 7/1/2025
Supported and Customized Employment Job Search and Placement - Outcome Report & Invoice Data Entry DJ Plautz 2025-07-01
Supported and Customized Employment Monthly Report Data Entry DJ Plautz 2023-07-01
Supported and Customized Employment Extended Services for Youth Report & Invoice Data Entry DJ Plautz 2023-09-20 Active on 7/1/2023, updated on 9/29.
Supported and Customized Employment Job Coaching/Job Support Report & Invoice Data Entry DJ Plautz 2025-07-01
Supported and Customized Employment Verification of Employee Hours Worked Data Entry DJ Plautz 2023-09-01
Supported and Customized Employment - Side by Side Referral Decision Guide DJ Plautz 2023-07-01 Provided by the Vocational Rehabilitation Technical Assistance Center for Quality Employment (VRTAC-QE) . tacqe.com
Supported and Customized Employment Fiscal Chart Print
 DJ Plautz 2025-07-01
Supported and Customized Employment Provider Handbook Print
 DJ Plautz 2025-07-01
Supported/Customized Employment Payment Schedule DJ Plautz 2024-07-01
Supported Employment Provider Questions DJ Plautz 2026-01-16

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 2019-04-30
Pre-Employment Transition Services Consent for a Paid Work Based Learning Experience (16+ y.o.) Print
Data Entry 		Lupe Stevens 2019-04-30
Pre-Employment Transition Services Work-Based Learning Experience Information Lindsay Brown 2022-05-05
Work-Based Learning Experience (WBLE) Timesheet Print
Data Entry 		Lindsay Brown 2023-06-13 work-based
Pre-Employment Transition Services Work-Based Learning Experience Report Print
Data Entry 		Lupe Stevens 2019-06-20
Pre-Employment Transition Services Work-Based Learning Experience (WBLE) Checklist Print
Data Entry 		Lupe Stevens 2023-08-29
Pre-Employment Transition Services Consent for a Non-paid Work Based Learning Experience Print
Data Entry 		Lupe Stevens 2019-04-30
Pre-Employment Transition Services Consent for a Paid Work Based Learning Experience (14-15 y.o.) Spanish Print
Data Entry 		Lupe Stevens 2019-04-30
Pre-Employment Transition Services Consent for a Paid Work Based Learning Experience (16+ y.o.) Spanish Print
Data Entry 		Lupe Stevens 2019-04-30
Pre-Employment Transition Services Work-Based Learning Experience Information Spanish Lindsay Brown 2022-05-04
Pre-Employment Transition Services Consent & Information Release - English Print
Data Entry 		Lupe Stevens 2023-05-16
Pre-Employment Transition Services Consent & Information Release - Spanish Print
Data Entry 		Lupe Stevens 2023-05-16
Pre-Employment Transition Services Consent for Non-paid Work Based Learning Experience Spanish Print
Data Entry 		Lupe Stevens 2019-04-30
Nebraska VR/SPED Inter-Departmental Agreement Print
 Lindy Foley 2018-08-22 Inter-departmental agreement between Nebraska VR and the Office of Special Education (SPED)
Signing of VR Documents chart Print
 Carla Lasley 2019-04-02
Pre-Employment Transition Services Release of Information English Print
Data Entry 		Lupe Stevens 2020-04-29
Pre-Employment Transition Services Release of Information Spanish Print
Data Entry 		Lupe Stevens 2020-04-30
Transition Services Partnership Planner Lupe Stevens 2021-08-16
W-4 Employee's Withholding Allowance Certificate Print
Data Entry 		Holly Enriquez 2026-01-07
I-9 Form & Information Print
 Amy Hancock 2024-03-06 Amy Hancock provided this update on 10-31-23
W-4N Employee’s Nebraska Withholding Allowance Certificate Print
Data Entry 		Holly Enriquez 2023-07-05
On-Line Access to Pay Stub - English Print
 Cathy Callaway 2026-01-07 Approved by Kaylee Huenink
Class Work Site Observation Checklist Print
Data Entry 		Kristi Berst 2021-04-02
2026 OJE/TWE/WBLE Bi-weekly Payroll Schedule Print
 Melysa Johnson 2025-12-16
Optional Invoice for Providers WSST/Job Coaching 7/23 Amy Hancock 2023-11-20
2025 OJE/TWE/WBLE Bi-weekly Payroll Schedule Melysa Johnson 2024-12-11
Pre-ETS Letter Non Participation - English Lindsay Brown 2025-01-28
Pre-ETS Letter Non Participation - Spanish Lindsay Brown 2025-01-28
Pre-ETS Letter Termination after Graduation - English Lindsay Brown 2025-01-28
Pre-ETS Letter Termination after Graduation - Spanish Lindsay Brown 2025-01-28
Pre-ETS Letter Change of Contact - English Lindsay Brown 2025-01-28
Pre-ETS Letter Change of Contact - Spanish Lindsay Brown 2025-01-28
Pre-ETS Letter Welcome - English Lindsay Brown 2025-01-28
Pre-ETS Letter Welcome - Spanish Lindsay Brown 2025-01-28
Pre-ETS Letter Termination - English Lindsay Brown 2025-10-07
Pre-ETS Letter Termination - Spanish Lindsay Brown 2025-10-30 Coming soon!
Pre-ETS Benefits Orientation Flowchart Lindsay Brown 2025-10-30
Pre-ETS Benefits Orientation Information - English Lindsay Brown 2025-12-09
Pre-ETS Benefits Orientation Information - Spanish Lindsay Brown 2025-12-09

Administrative

Administrative - NDE

Form Name Action Form Owner Revision Date Notes
Volunteer/Unpaid Intern Print
 Holly Enriquez This form is housed on Inside NDE.
Direct Deposit Enrollment Print
Data Entry 		Cinda Wacker 2013-07-31
Horizontal Wage Progression Holly Enriquez Contact NDE HR for this form.
I-9 Checklist Print
 Holly Enriquez
I-9 Form & Information Print
 Amy Hancock 2024-03-06 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 2023-07-05
ADA Guidance Print
 Holly Enriquez 2017-02-24
Work Opportunity Tax Credits - 8850 - Pre-Screening Notice & Certification Request Instructions Print
 Michael Enriquez
2026 OJE/TWE/WBLE Bi-weekly Payroll Schedule Print
 Melysa Johnson 2025-12-16
2025 OJE/TWE/WBLE Bi-weekly Payroll Schedule Melysa Johnson 2024-12-11

Administrative - Nebraska VR

Form Name Action Form Owner Revision Date Notes
Confidentiality Agreement Print
 Holly Enriquez 2021-07-27
Incident/Accident/Injury Report for Clients & Applicants Print
Data Entry 		Holly Enriquez 2023-02-08
Direct Purchase Authorization (DPA) Print
Data Entry 		Cathy Callaway
Employee Roster Information Print
Data Entry 		Holly Enriquez 2017-05-03
Position Information Sheet Associate Print
Data Entry 		Holly Enriquez 2019-10-25
Position Information Sheet Service/Rehab Specialists Print
Data Entry 		Holly Enriquez 2019-10-25
Supported Employment Case Review DJ Plautz 2024-07-01
Service Agreement Data Entry Carla Lasley 2026-03-26
Training Request Print
Data Entry 		Ken Cuevas 2020-02-18
TSB Official Travel Log Print
 Melysa Johnson 2026-01-01 Added heading with printed Driver's first name.
Video and Media Information Release for Clients Print
Data Entry 		Sarah Chapin 2025-04-29 Release of Information, Media Release, Consent for Media
I-9 Checklist Print
 Holly Enriquez
State Vehicle Waiver - VR English and Spanish Print
 Holly Enriquez 2019-06-04 English and Spanish waiver
Nebraska VR Office Listing Print
 Cathy Callaway 2026-02-26
Suicide Call Form Print
Data Entry 		Holly Enriquez 2015-12-16
Code of Conduct Print
Data Entry 		Angela Fujan 2021-02-01
Summary of Case Review Findings Print
Data Entry 		Angela Fujan 2020-01-13
Transition Partnership Planning Form Data Entry Lupe Stevens 2021-08-17 Link to web form for the Transition Services Partnership Planner - Guide for Educators
Training Plan Data Entry Ken Cuevas 2018-09-19
18/23 Month Assessment Action Plan Print
Data Entry 		Holly Enriquez 2018-09-05
Order of Selection (OOS) Talking Points Print
Data Entry 		Lindy Foley 2018-05-03
Nebraska VR/SPED Inter-Departmental Agreement Print
 Lindy Foley 2018-08-22 Inter-departmental agreement between Nebraska VR and the Office of Special Education (SPED)
Continuity of Operations Plan (COOP) for COVID-19 Print
 Lindy Foley 2021-08-26
Nebraska VR Question and Answers Continuity of Operations Plan (COOP)- COVID 19 Print
 Lindy Foley 2021-04-01
2026 OJE/TWE/WBLE Bi-weekly Payroll Schedule Print
 Melysa Johnson 2025-12-16
External Agency/Business Partner Media Release Data Entry Michael Enriquez 2022-03-16
Request Temporary Access Print
 Holly Enriquez 2022-06-06
Compliance Review (Download Word Document) Cathy Callaway 2024-06-12
Quality Review (Download Word Document) Cathy Callaway 2024-06-12
2025 OJE/TWE/WBLE Bi-weekly Payroll Schedule Melysa Johnson 2024-12-11

Administrative - State of Nebraska

Form Name Action Form Owner Revision Date Notes
Voter Registration Form English Print
Data Entry 		Holly Enriquez 2025-12-22
Tax Exempt Form (Form 13) Print
 Cathy Callaway 2025-07-22 Office Listing is included with the form
W-4 Employee's Withholding Allowance Certificate Print
Data Entry 		Holly Enriquez 2026-01-07
W-9 & ACH Enrollment Print
Data Entry 		Cinda Wacker
Exception Request-CSI Furniture (SPB Form 9) Print
Data Entry 		Holly Enriquez 2025-10-15
Voter Registration Form Spanish Print
Data Entry 		Holly Enriquez 2025-12-22
W-4N Employee’s Nebraska Withholding Allowance Certificate Print
Data Entry 		Holly Enriquez 2023-07-05
Voter Registration Disclaimer Print
 Holly Enriquez 2020-04-01
Voter Registration Disclaimer-Spanish Print
 Holly Enriquez 2020-04-14
Records Transfer Sheet Print
 Holly Enriquez 2023-04-06

back to top