Fillable DR397R Request For CCIR Services (California)

Fill Online, Printable, Fillable, Blank DR397R Request For CCIR Services (California) Form

Use Fill to complete blank online CALIFORNIA pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

DR397R Request For CCIR Services (California)

On average this form takes 13 minutes to complete

The DR397R Request For CCIR Services (California) form is 2 pages long and contains:

  • 0 signatures
  • 34 check-boxes
  • 37 other fields

Country of origin: US
File type: PDF

BROWSE CALIFORNIA FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
STATE OF CALIFORNIA
DEPARTMENT OF REHABILITATION
Section 511 Career Counseling and Information and Referral (CC&IR)
Request for Initial CC&IR Services
DR397R (New 01/21)
Page 1 of 4
14(c) Worker Name/CC&IR Recipient
Preferred Name
Street Address, City, and Zip Code
Phone Number
Date of Birth
Email Address
Gender
Male
Female
Decline to State
What is your race and ethnicity? (check all that may apply)
American Indian/Alaskan Native
Black or African American
Cambodian
Filipino
Guamanian or Chamorro
Hispanic or Latino
Japanese
Laotian
Other Asian
Samoan
Vietnamese
Decline to State
Need an Interpreter?
Primary Source of Support (select one)
Yes
All Other Sources
Personal Income
Decline to State
Language ________________
Family and Friends
Public Support (SSI, SSDI, TANF, etc.)
Regional Center Name
UCI#
Legal Guardian/Conservator Name
Relationship
Email Address
Phone Number
14(C) WORKER/CC&IR RECIPIENT CONSENT FOR RELEASE AND SHARING OF REQUESTED INFORMATION
I give permission to the 14(c) Employer and the Department of Rehabilitation to share information
relevant to my CC&IR services with each other, and with the Regional Center listed above as
appropriate.
14(c) Worker/CC&IR Recipient Signature
Print Name
Date
STATE OF CALIFORNIA
DEPARTMENT OF REHABILITATION
Section 511 Career Counseling and Information and Referral (CC&IR)
Request for Initial CC&IR Services
DR397R (New 01/21)
Page 2 of 3
LEGAL GUARDIAN/CONSERVATOR CONSENT [IF REQUIRED]
I declare that I am the legal guardian/conservator of the 14(c) Worker/CC&IR Recipient named above and
I have the legal right to authorize this consent.
Authorized Signature
Print Name
Date
To be Completed by 14(c) Certificate Holder/Employer Representative:
14(c) Certificate Holder (Employer) Name of Record
14(c) Employer Work Site Name (If different)
Street Address, City, Zip Code
14(c) Employer Email Address
14(c) Employer Phone
14(c) Worker/CC&IR Recipient
DOL 14(c) Worker/CC&IR Recipient Primary Impairment
Wage Earning Start Date _____________
Intellectual/Developmental
Substance Abuse
Average Hourly Wage _______________
Psychiatric
Neuromuscular
Work Setting
Visual Impairment
Age Related
Sheltered Workshop
Hearing Impairment
Group Placement
Other (Specify) ________________________________
Authorized 14(c) Employer Representative Signature
Print Name/Title
Date
FORM PURPOSE AND COMPLETION INSTRUCTIONS
This form is intended for use by the 14(c) Employer Representative in collaboration with the 14(c) Worker
to notify the Department of Rehabilitation (DOR) of the request for Career Counseling and Information and
Referral (CC&IR) services for an individual newly hired for subminimum wage employment. Pursuant to
Workforce Innovation and Opportunity Act Section 511 34 CFR 397, the DOR must provide, at certain
prescribed intervals for the duration of such employment, career counseling and information and referral
services, designed to promote opportunities for competitive integrated employment, to individuals with
disabilities, regardless of age, who are known to be employed at subminimum wage. In support of the
Home and Community-Based Services Final Rule, individuals working in a non-integrated employment
setting may also request CC&IR services to learn about their options and services to pursue competitive
integrated employment.
1. 14(c) Worker/CC&IR Recipient: Complete the top portion of this form. This information will be used
to:
a. Identify and record the appropriate Career Counseling and Information and Referral (CC&IR)
services that will support the individual’s goals.
STATE OF CALIFORNIA
DEPARTMENT OF REHABILITATION
Section 511 Career Counseling and Information and Referral (CC&IR)
Request for Initial CC&IR Services
DR397R (New 01/21)
Page 3 of 3
b. Partner with the 14(c) Employer and Regional Center regarding the coordination of potential
employment and support services, as appropriate.
c. Conduct aggregate analysis of demographic data trends that support quality services.
2. 14(c) Worker/CC&IR Recipient and Guardian Conservator, as appropriate: Review the information
provided for accuracy, and sign to designate approval for the 14(c) Employer to submit the form to the
DOR Achieving Community Employment (ACE) Team.
3. 14(c) Employer Representative:
a. Review the information provided; and, complete the bottom portion and sign the form.
b. Submit completed, signed form to DOR ACE Team 511 CCIR@dor.ca.gov.
c. Retain a copy for your records.
4. DOR ACE Team: Upon receipt of this form, the ACE Team will:
a. Assign the new 14(c) Worker/CC&IR Recipient to the regional ACE Rehabilitation Counselor
and open a DOR record of services to document the CC&IR services needed and provided.
b. Schedule person-centered CC&IR services that meet the individual’s needs and employment
related interests.
PRIVACY STATEMENT
An individual, with the Legal Guardian or Conservator if applicable, has the right to inspect information
maintained by DOR about the individual, unless otherwise prohibited or conditioned by law or regulation.
For assistance accessing such information, contact DOR.
If information is released to an individual or agency with the informed, written consent of the individual to
whom the information pertains, the receiving individual or agency should be aware that the information
from DOR is confidential. Federal regulation and state law and regulation prohibit any further disclosure
of this information without the informed, written consent of the individual to whom this information pertains,
unless otherwise permitted by law.
Any personal information collected by the DOR is subject to the limitations in the California Information
Practices Act (Civ. Code § 1798 et seq.), Title 34 Code of Federal Regulations section 361.38, and
California Code of Regulations, title 9, sections 7140 through 7143.5. The DOR may release personal
information in response to a court order, investigations in connection with law enforcement, fraud, or abuse,
subject to the limitations set forth in California Code of Regulations, title 9, section 7143.5 (34 C.F.R. §
361.38(e) (4) and (5)).
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

DR397R Request For CCIR Services (California)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 30 May 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document