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VR Forms

Form Name Owner Revision Date
Optional Invoice for Providers WSST/Job Coaching 7/23 Amy Hancock 11/20/2023
(TWE) Trial Work Experience Agreement Kristi Berst 02/23/2022
15 Day Letter - English Angela Fujan 02/14/2020
15 Day Letter - Spanish Angela Fujan 05/11/2022
18/23 Month Assessment Action Plan Holly Enriquez 09/05/2018
2024 OJE/TWE/WBLE Bi-weekly Payroll Schedule Melysa Johnson 12/13/2023
A Guide for Supporting Individuals With Developmental Disabilities In The Workplace Cathy Callaway 11/01/2010
ABI/Autism SE Supplemental Questionnaire Carla Lasley 11/30/2018
AbilityOne Process Paige Rose 04/01/2022
Acceptance Agreement Form (Equipment Agreement) Mary Matusiak 02/28/2021
Action Planner Angela Fujan 08/31/2011
ADA Guidance Holly Enriquez 02/24/2017
Agrability Referral Angela Fujan 03/31/2014
Application - English Angela Fujan 10/20/2023
Application - Spanish Angela Fujan 10/20/2023
Appointment Reminder Postcard Sarah Chapin 05/20/2014
Assessment for Competitive Integrated Employment Determination Checklist Kristi Berst 04/01/2024
Assessment Services Cathy Callaway 04/08/2022
Assessment Supports Cathy Callaway 07/01/2023
Assignment Purchases-Medicare Cathy Callaway
Assignment Purchases-Third Party Cathy Callaway
ATP-CPAP Facility Assessment Referral Form Nancy Noha 07/18/2017
ATP/VR Referral Nancy Noha 03/27/2024
Authorization for Exchange of Information-Multi Agency Release Carla Lasley 04/30/2019
Background Screen Release of Information (Disclosure and Authorization Form) Mary Matusiak
Benefits Orientation/Referral for Benefits Services Carla Lasley 04/12/2024
Benefits Provider Choice or Declination - English Carla Lasley 08/23/2024
Benefits Provider Choice or Declination - Spanish Carla Lasley 08/23/2024
Blank Memo Post Card Sarah Chapin
BP/DHHS Authorization for the Disclosure of Protected Health Information Carla Lasley 01/22/2020
BP/DHHS Authorization for the Disclosure of Protected Health Information-Spanish Carla Lasley 01/22/2020
BP/SSA 3288 Consent for Release of Information - General English Carla Lasley 11/10/2021
BP/SSA 3288 Consent for Release of Information - General Spanish Carla Lasley 11/10/2021
Budget Worksheet-Education Financial Aid Angela Fujan 03/02/2016
Budget Worksheet-Post-Secondary Angela Fujan 05/31/2006
Career Planning Preferences - English Angela Fujan 01/01/2016
Career Planning Preferences - Spanish Angela Fujan 04/15/2020
Case File Order List Angela Fujan 06/04/1919
Case File Request for Information Cathy Callaway 04/13/2023
Case Review - Compliance (Draft) Holly Enriquez 06/30/2024
Case Review - Quality (Draft) Holly Enriquez 06/30/2024
Class Work Site Observation Checklist Paige Rose 04/02/2021
Client Reimbursement Cathy Callaway 04/30/2019
Client User ID Password Letter Cathy Callaway 07/15/2021
Clients Removed from Wait List Who are Working Paige Rose 02/25/2020
Code of Conduct Angela Fujan 02/01/2021
Communication Assessment - English Angela Fujan 01/24/2023
Communication Assessment - Spanish Angela Fujan 01/24/2023
Compliance Review (Download Word Document) Cathy Callaway 06/12/2024
Concurrent Work Incentives Guide 2023 - English Carla Lasley 01/30/2023
Concurrent Work Incentives Guide 2023 - Spanish Carla Lasley 07/19/2023
Concurrent Work Incentives Guide 2024 - English Carla Lasley 03/25/2024
Concurrent Work Incentives Guide 2024 - Spanish Carla Lasley 03/25/2024
Confidentiality Agreement Holly Enriquez 07/27/2021
Contact Letter - English Angela Fujan 04/17/2019
Contact Letter - Spanish Angela Fujan 04/25/2022
Continuity of Operations Plan (COOP) for COVID-19 Lindy Foley 08/26/2021
Contracts, Letter Contracts, Purchasing Procedures Cathy Callaway
Corrective Action Plan Cathy Callaway 04/30/2019
CPAP 2.0 Individualized Business Plan (IBP) Mary Kunes-Neary 08/16/2022
CSI Exception Request Holly Enriquez 09/23/2024
Direct Deposit Enrollment Cinda Wacker 07/31/2013
Direct Purchase Authorization (DPA) Cathy Callaway
Discovery Activity: Application for Employment - English Angela Fujan 05/11/2023
Discovery Activity: Application for Employment - Spanish Angela Fujan 05/11/2023
Discovery Activity: Family Support Network - English Angela Fujan 05/11/2023
Discovery Activity: Family Support Network - Spanish Angela Fujan 05/11/2023
Discovery Activity: Job Skills - English Angela Fujan 05/11/2023
Discovery Activity: Job Skills - Spanish Angela Fujan 05/11/2023
Discovery Activity: Make Sure - English Angela Fujan 05/11/2023
Discovery Activity: Make Sure - Spanish Angela Fujan 05/11/2023
Discovery Activity: Non-Paid Work Experiences - English Angela Fujan 05/11/2023
Discovery Activity: Non-Paid Work Experiences - Spanish Angela Fujan 05/11/2023
Discovery Activity: Work Considerations - English Angela Fujan 05/11/2023
Discovery Activity: Work Considerations - Spanish Angela Fujan 05/11/2023
Discovery Activity: Work Interests - English Angela Fujan 05/11/2023
Discovery Activity: Work Interests - Spanish Angela Fujan 05/11/2023
Discovery Activity: Work Preferences - English Angela Fujan 05/11/2023
Discovery Activity: Work Preferences - Spanish Angela Fujan 05/11/2023
Discovery Activity: Work Values - English Angela Fujan 05/11/2023
Discovery Activity: Work Values - Spanish Angela Fujan 05/11/2023
Electronic Case File Categories/Attachment Types Cathy Callaway 04/01/2024
Eligibility Letter - English Angela Fujan 07/01/2024
Eligibility Letter - Spanish Angela Fujan 05/07/2020
Emancipated Minor Form Carla Lasley 04/02/2019
Employee Roster Information Holly Enriquez 05/03/2017
Employment Success Skills Mary Matusiak 10/09/2024
Exit Status Decision Tree Paige Rose
External Agency/Business Partner Media Release Mary Matusiak 03/16/2022
Fax Log Tibor Moldovan 05/01/2020
Financial Aid Budget Information Angela Fujan 02/03/2011
Focus Card Enrollment Form Amy Hancock 07/05/2023
Functional Capacities Checklist Angela Fujan 04/10/2019
Functional Cognitive Assessment Referral Keri Bennett 10/29/2024
Guide for Approval of Eligibility and Priority Groups Angela Fujan 11/30/2017
Guide for Nebraska VR Staff Requesting Information from NE Department of Correctional Services Holly Enriquez 08/25/2022
High Cost Request Angela Fujan 09/24/2019
Horizontal Wage Progression Holly Enriquez
I-9 Checklist Holly Enriquez
I-9 Form & Information Amy Hancock 03/06/2024
IL Assessment-Barriers to Employment Carla Lasley 07/31/2008
IL Assessment-Household, Relocation, Cleaning Carla Lasley
IL Assessment-Menu Planning/Prep, Laundry/Clothing Care, Daycare Carla Lasley 07/31/2008
IL Assessment-Rehab Engineering & Assistive Tech Carla Lasley 07/31/2008
IL Assessment-School Needs Carla Lasley 07/31/2008
IL Assessment-Transportation, Health & Hygiene Carla Lasley 07/31/2008
IL Assessment-Work-Site Needs/Accommodations Carla Lasley 07/31/2008
Impairments Checklist Angela Fujan 08/09/2019
Impediment Questions Angela Fujan 04/04/2019
Incident/Accident/Injury Report for Clients & Applicants Holly Enriquez 02/08/2023
Individualized Plan for Employment (IPE) - English Cathy Callaway 07/01/2023
Individualized Plan for Employment (IPE) - Spanish Cathy Callaway 07/06/2023
Information and Referral (I & R) to Other Programs Paige Rose 07/12/2022
Information and Referral (I & R) to Other Programs - Spanish Paige Rose 07/12/2022
Informational Interview Questionnaire Paige Rose 11/20/2018
Initial Meeting Questions Angela Fujan 08/01/2019
Initial Meeting to Next Step Guide Angela Fujan 03/31/2021
IPE Guide Angela Fujan 08/30/2019
IPE Services Cathy Callaway 04/08/2022
Job Facts Guide Mary Matusiak 05/31/2014
Job Planning Factors & Job Planning Discussion Angela Fujan 10/26/2021
Job Readiness Factors & Initial Meeting - A Guide for Staff Angela Fujan 10/26/2021
Job Search Agreement and Consent - English Mary Matusiak 03/16/2023
Job Search Agreement and Consent - Spanish Mary Matusiak 03/16/2023
Job Seeking Skills Training Application Mary Matusiak
Job Seeking Skills Training Booklet - English Mary Matusiak 12/01/2017
Key VR Time Frames Angela Fujan 01/02/2019
List of Background Checks Carla Lasley 01/05/2024
Maximus: Notification To Take Ticket Out of Assignment Carla Lasley 09/30/2012
Mediation Referral Angela Fujan 04/30/2019
Medicaid Spreadsheet (No Insurance) Amy Hancock
Medicaid Spreadsheet (With Insurance) Amy Hancock
Merit Stipend Request Holly Enriquez
NCBVI and Nebraska VR MOU Angela Fujan
NE VR Sign Language Interpreting Request Vicki Steinhaur-Campbell 05/05/2016
Nebraska VR ABI Interview Keri Bennett 05/24/2022
Nebraska VR Question and Answers Continuity of Operations Plan (COOP)- COVID 19 Lindy Foley 04/01/2021
Nebraska VR/SPED Inter-Departmental Agreement Lindy Foley 08/22/2018
Next Steps - English Angela Fujan 11/30/2010
Next Steps- Spanish Angela Fujan 11/30/2015
Office Director Letter Angela Fujan 10/07/2022
OJE/TWE Checklist Kristi Berst 02/25/2022
OJE/TWE Consent Kristi Berst 01/12/2022
OJE/TWE Timesheet Kristi Berst 01/12/2022
OJT Letter Mary Matusiak 01/12/2022
On-Line Access to Pay Stub - English Cathy Callaway 10/29/2024
On-line Access to Pay Stub - Spanish Cathy Callaway 10/29/2024
On-the-Job Report Kristi Berst 07/01/2020
OOS Off Wait List Letter - English Angela Fujan 02/25/2020
OOS Off Wait List Letter - Spanish Angela Fujan 11/18/2022
OOS Upgrading Priority Group Letter - English Angela Fujan 08/04/2021
OOS Upgrading Priority Group Letter - Spanish Angela Fujan 08/27/2021
Order of Selection (OOS) Fact Sheet Angela Fujan 10/03/2022
Order of Selection (OOS) Fact Sheet Spanish Angela Fujan 10/03/2022
Order of Selection (OOS) Questions & Answers Angela Fujan 05/08/2018
Order of Selection (OOS) Talking Points Lindy Foley 05/03/2018
Order of Selection communication to VR staff on process for working with BH Regions while all categories are closed Lindy Foley 06/04/2018
Order of Selection Communication to VR staff on process for working with DDD while all categories are closed Lindy Foley 06/04/2018
Order of Selection Job Retention Questions Angela Fujan 03/31/2019
Order of Selection Retention Letter Angela Fujan 11/19/2020
Order of Selection Update for BH SE Milestones Carla Lasley 07/18/2018
Orientation Welcome Letter-Word version Sarah Chapin 12/14/2017
Pearls of Placement Reference Guide Mary Matusiak 01/24/2024
Physical Capacities Angela Fujan 02/28/2014
Position Information Sheet Associate Holly Enriquez 10/25/2019
Position Information Sheet Service/Rehab Specialists Holly Enriquez 10/25/2019
Post Secondary Training Justification - PDF Angela Fujan 09/30/2010
Post Secondary Training Justification - Word doc Angela Fujan 09/30/2010
Pre-Employment Transition Services Consent & Information Release - English Lupe Stevens 05/16/2023
Pre-Employment Transition Services Consent & Information Release - Spanish Lupe Stevens 05/16/2023
Pre-Employment Transition Services Consent for a Non-paid Work Based Learning Experience Lupe Stevens 04/30/2019
Pre-Employment Transition Services Consent for a Paid Work Based Learning Experience (14-15 y.o.) Lupe Stevens 04/30/2019
Pre-Employment Transition Services Consent for a Paid Work Based Learning Experience (14-15 y.o.) Spanish Lupe Stevens 04/30/2019
Pre-Employment Transition Services Consent for a Paid Work Based Learning Experience (16+ y.o.) Lupe Stevens 04/30/2019
Pre-Employment Transition Services Consent for a Paid Work Based Learning Experience (16+ y.o.) Spanish Lupe Stevens 04/30/2019
Pre-Employment Transition Services Consent for Non-paid Work Based Learning Experience Spanish Lupe Stevens 04/30/2019
Pre-Employment Transition Services Non Participation Letter - English Lupe Stevens 12/19/2019
Pre-Employment Transition Services Non Participation Letter - Spanish Lupe Stevens 09/02/2022
Pre-Employment Transition Services Release of Information English Lupe Stevens 04/29/2020
Pre-Employment Transition Services Release of Information Spanish Lupe Stevens 04/30/2020
Pre-Employment Transition Services Termination after Graduation Letter - English Lupe Stevens 08/02/2019
Pre-Employment Transition Services Termination after Graduation Letter - Spanish Lupe Stevens 04/03/2020
Pre-Employment Transition Services Welcome Letter - English Lupe Stevens 10/20/2017
Pre-Employment Transition Services Welcome Letter - Spanish Lupe Stevens 10/20/2017
Pre-Employment Transition Services Work Based Learning Letter-Paid Lupe Stevens 08/30/2017
Pre-Employment Transition Services Work Based Learning Letter-Unpaid Lupe Stevens 08/30/2017
Pre-Employment Transition Services Work-Based Learning Experience (WBLE) Checklist Lupe Stevens 08/29/2023
Pre-Employment Transition Services Work-Based Learning Experience Information Lindsay Brown 05/05/2022
Pre-Employment Transition Services Work-Based Learning Experience Information Spanish Lindsay Brown 05/04/2022
Pre-Employment Transition Services Work-Based Learning Experience Report Lupe Stevens 06/20/2019
Pre-ETS Job Exploration Referral Paige Rose 01/24/2023
Progressive Employment Model Mary Matusiak 03/31/2022
Proof of Purchase Cathy Callaway 04/30/2019
Provider Invoice Cathy Callaway 02/28/2013
Purchase of Goods and Services Angela Fujan 05/01/2017
Q & A on Employment Plans Carla Lasley 06/19/2018
Quality Review (Download Word Document) Cathy Callaway 06/12/2024
Records Transfer Sheet Holly Enriquez 04/06/2023
Release of Information English Angela Fujan 02/13/2024
Release of Information Spanish Angela Fujan 02/13/2024
Request for Certificate of Self-Insurance Holly Enriquez 07/01/2024
Request for Medical Information - English Angela Fujan 04/01/2019
Request for Medical Information - Spanish Angela Fujan 04/01/2019
Request Temporary Access Holly Enriquez 06/06/2022
Schedule A Certification Letter for VR Staff Mary Matusiak 10/01/2018
Section 511 Decision Tree Paige Rose 07/07/2020
Section 511 Decision Tree for Staff Only Paige Rose 07/07/2020
Section 511: CCIR Case Review Checklist Paige Rose 01/24/2023
Section 511: Discovery Payment Schedule Paige Rose 11/27/2018
Section 511: Documentation Checklist for Adults (age 25 and older) Paige Rose 02/24/2020
Section 511: Documentation Checklist for Youth (Age 24 and younger) Paige Rose 02/24/2020
Section 511: Employment Not Expected from Services Letter Paige Rose 09/08/2020
Section 511: Refusal of Pre-Employment Transition Services (While still in High School) Paige Rose 11/30/2020
Section 511: Refusal to Participate - English Paige Rose 01/27/2023
Section 511: Refusal to Participate - Spanish Paige Rose 01/27/2023
Self Employment Discussion Questionnaire-Data Entry Julie Shively 03/24/2021
Self Employment Feasibility Referral Form Julie Shively 05/23/2022
Self Employment Personal Finance Worksheet Julie Shively 02/07/2017
Self Employment Process Chart Julie Shively 01/26/2018
Self Employment Rates & Hourly Estimates Mary Matusiak 05/25/2023
Self Employment-Advantages Julie Shively 03/01/2017
Self-Employment - Green Flags/Red Flags Julie Shively 12/10/2021
Service & Device Application - English Nancy Noha 10/20/2023
Service & Device Application - Spanish Nancy Noha 10/20/2023
Service Agreement DJ Plautz 01/08/2024
Signing of VR Documents chart Carla Lasley 04/02/2019
SOS Personnel Request form (Will download to your Downloads folder) Holly Enriquez
Sources & Uses of Funds Julie Shively 04/09/2021
State Vehicle Waiver - VR English and Spanish Holly Enriquez 06/04/2019
State VR SSA Coordinators Carla Lasley 07/07/2022
Student Financial Aid Report (SFAR-E) Angela Fujan 08/14/2024
Substance Use Disorders- VR Desk Reference Angela Fujan 11/18/2022
Successful Outcome Letter (Non SSA) in English Angela Fujan 10/07/2022
Successful Outcome Letter (Non SSA) in Spanish Angela Fujan 10/07/2022
Successful Outcome Letter (SS beneficiaries) in English Carla Lasley 10/07/2022
Successful Outcome Letter (SS beneficiaries) in Spanish Carla Lasley 10/07/2022
Suicide Call Holly Enriquez 02/28/2009
Suicide Call Form Holly Enriquez 12/16/2015
Summary of Case Review Findings Angela Fujan 01/13/2020
Summary of Initial Meeting Angela Fujan 04/04/2019
Summary of Initial Meeting-Spanish Angela Fujan 04/04/2019
Supported and Customized Employment - Side by Side Referral Decision Guide DJ Plautz 07/01/2023
Supported and Customized Employment Extended Services for Youth Report & Invoice DJ Plautz 09/20/2023
Supported and Customized Employment Fiscal Chart DJ Plautz 11/22/2023
Supported and Customized Employment Job Coaching/Job Support Report & Invoice DJ Plautz 09/01/2023
Supported and Customized Employment Job Search and Placement - Outcome Report & Invoice DJ Plautz 09/01/2023
Supported and Customized Employment Job Stability Report DJ Plautz 07/01/2023
Supported and Customized Employment Monthly Report DJ Plautz 07/01/2023
Supported and Customized Employment Plan for Job Development - Outcome Report & Invoice DJ Plautz 09/01/2023
Supported and Customized Employment Provider Handbook DJ Plautz 11/22/2023
Supported and Customized Employment Referral DJ Plautz 07/01/2023
Supported and Customized Employment Verification of Employee Hours Worked DJ Plautz 09/01/2023
Supported Employment Case Review DJ Plautz 07/01/2024
Supported Self-Employment Guidance Mary Matusiak 05/23/2018
Supported/Customized Employment Payment Schedule DJ Plautz 07/01/2024
Tax Exempt Form (Form 13) Cathy Callaway 07/17/2024
Template, Background, & Instructions for Completion of Employment Plan (I/DD) Carla Lasley
Template, Background, Instructions for BH Employment Plan Carla Lasley 07/09/2018
Termination Letter for Non SSA Recipients in English Angela Fujan 10/07/2022
Termination Letter for Non SSA Recipients in Spanish Angela Fujan 10/12/2022
Termination Letter for SSA Recipients in English Carla Lasley 10/07/2022
Termination Letter for SSA Recipients in Spanish Carla Lasley 10/07/2022
Time Conversion Chart Cathy Callaway
Title II: Social Security Disability Insurance Work Incentives Guide 2023 - English Carla Lasley 01/30/2023
Title II: Social Security Disability Insurance Work Incentives Guide 2023 - Spanish Carla Lasley 01/30/2023
Title II: Social Security Disability Insurance Work Incentives Guide 2024 - English Carla Lasley 12/26/2023
Title II: Social Security Disability Insurance Work Incentives Guide 2024 - Spanish Carla Lasley 12/26/2023
Title XVI: Supplemental Security Income Work Incentive Guide 2023 - English Carla Lasley 01/30/2023
Title XVI: Supplemental Security Income Work Incentive Guide 2023 - Spanish Carla Lasley 07/19/2023
Title XVI: Supplemental Security Income Work Incentives Guide 2024 - English Carla Lasley 03/25/2024
Title XVI: Supplemental Security Income Work Incentives Guide 2024 - Spanish Carla Lasley 03/25/2024
Training Plan Ken Cuevas 09/19/2018
Training Request Ken Cuevas 02/18/2020
Transition Partnership Planning Form Lupe Stevens 08/17/2021
Transition Services Partnership Planner Lupe Stevens 08/16/2021
TSB Log Melysa Johnson
Viability Referral Angela Fujan 06/14/2021
Video & Media Information Release (Client) Sarah Chapin 04/30/2019
Video Conference Participant List Paige Rose 11/09/2018
Vocational Evaluation Referral Paige Rose 12/08/2022
Volunteer/Non-Paid Accident Coverage Holly Enriquez 08/07/2024
Volunteer/Unpaid Intern Holly Enriquez
Voter Registration Disclaimer Holly Enriquez 04/01/2020
Voter Registration Disclaimer-Spanish Holly Enriquez 04/14/2020
Voter Registration Form Spanish Holly Enriquez 06/24/2024
Voter Registration Form English Holly Enriquez 06/24/2024
VR Financial Aid Angela Fujan 11/10/2022
VR Process Chart Angela Fujan 10/26/2021
VR Profile for Supported or Customized Employment Paige Rose 04/30/2019
VR Psychological Narrative Report Guidelines Angela Fujan 08/31/2006
VR Referral Form - English Angela Fujan 10/20/2023
VR Referral Form - Spanish Angela Fujan 10/20/2023
VR Vendor Office Listing Cathy Callaway 12/31/2012
VR/SSA 3288 Consent for Release of Information - General English Carla Lasley 11/10/2021
VR/SSA 3288 Consent for Release of Information - General Spanish Carla Lasley 11/10/2021
W-4 Employee's Withholding Allowance Certificate Holly Enriquez 03/06/2024
W-4N Employee’s Nebraska Withholding Allowance Certificate Holly Enriquez 07/05/2023
W-9 & ACH Enrollment Cinda Wacker
Weekly Job Search Record Mary Matusiak
Welcome Letter with Link to Orientation Video-Constant Contact Sarah Chapin 07/10/2024
Work Opportunity Tax Credits - 8850 - Pre-Screening Notice & Certification Request - English Mary Matusiak
Work Opportunity Tax Credits - 8850 - Pre-Screening Notice & Certification Request - Spanish Mary Matusiak
Work Opportunity Tax Credits - 8850 - Pre-Screening Notice & Certification Request Instructions Mary Matusiak
Work Opportunity Tax Credits - 9061 Individual Characteristics - English Mary Matusiak
Work Opportunity Tax Credits - 9061 Individual Characteristics - Spanish Mary Matusiak
Work Schedule Holly Enriquez
Work-Based Learning Experience (WBLE) Timesheet Lindsay Brown 06/13/2023

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