Fillable De1277 DHS 1277 Service Questionnaire (Vocational Rehabilitation Services)

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De1277 DHS 1277 Service Questionnaire (Vocational Rehabilitation Services)

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Page 1 of 10 DHS 1277 (10/2016)
Service Questionnaire
If you need assistance completing this form please call your vocational rehabilitation office before
your intake appointment.
This document can be provided upon request in an alternate format for individuals with disabilities or
in a language other than English for people with limited English skills. To request this form in another
format or language, contact Vocational Rehabilitation at 503-945-5880 or email vr.info@state.or.us or
711 for TTY.
Personal information
Last name:
First name:
Middle name:
Preferred name:
Previous last name:
Birthdate:
Email address:
Gender:
Social Security Number:
- -
Phone number cell land other:
Second phone number: cell land other:
Home address:
Date residency began:
City:
State:
County:
ZIP code:
Mailing address (if different than above home address):
City:
State:
ZIP code:
Racial and ethnic background (check all that apply):
American Indian or Alaskan Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or other Pacific Islander
White
Other (specify):
Primary language (check all that apply):
English Spanish Other:
Counselor notes:
Have you been a prior client of Vocational Rehabilitation? Yes No
If yes, when and where?
Page 2 of 10 DHS 1277 (10/2016)
Personal information
Are you a US citizen? Yes No If no, do you have a work permit? Yes No
Contacts:
Name: Relationship: Phone number:
Name: Relationship: Phone number:
Counselor notes:
Your living situation:
Community residential/group home Halfway house (transition living)
Homeless/shelter Live with parents Private residence (independent)
Marital status: Never
Separated
Married
Widowed
Divorced
Domestic partner
Members living with you (check all that apply):
Self only Self/partner and/or children Parents Other:
Who referred you to this agency?
Income
Monthly average income: Amount:
How do you currently support yourself financially?
Social Security Income (SSI):
Social Security Disability Income (SSDI):
Temporary Assistance for Needy Families (TANF):
Supplemental Nutrition Assistance Program (SNAP):
Subtotal:
Source: Program: Amount:
Workers’ compensation:
Veterans:
Personal income:
Other:
Total:
Counselor notes:
Page 3 of 10 DHS 1277 (10/2016)
Medical insurance information
Check all that apply:
Medicaid
Medicare
OHP (Oregon Health Plan)
Private insurance (other)
Private insurance (own employer)
Public insurance (other)
Workers’ compensation
None
Counselor notes:
Employment
Are you currently employed? Yes No Hours per week: Salary:
Hourly wage:
Are you a migrant or seasonal farm worker? Yes No
Please list the most recent job you had first.
Employer 1:
Job title:
Job duties:
Did you have any difficulties with these duties because of your disability? Yes No
If yes, how?
Start date:
End date:
Last salary/pay rate:
Full time
Part time
Reason for leaving: Terminated Laid off Quit Relocated/moved Other
(Please explain):
Employer 2:
Job title:
Job duties:
Did you have any difficulties with these duties because of your disability? Yes No
If yes, how?
Start date:
End date:
Last salary/pay rate:
Full time
Part time
Reason for leaving: Terminated Laid off Quit Relocated/moved Other
(Please explain):
Page 4 of 10 DHS 1277 (10/2016)
Employment
Employer 3:
Job title:
Job duties:
Did you have any difficulties with these duties because of your disability? Yes No
If yes, how?
Start date:
End date:
Last salary/pay rate:
Full time
Part time
Reason for leaving: Terminated Laid off Quit Relocated/moved Other
(Please explain):
Employer 4:
Job title:
Job duties:
Did you have any difficulties with these duties because of your disability? Yes No
If yes, how?
Start date:
End date:
Last salary/pay rate:
Full time
Part time
Reason for leaving: Terminated Laid off Quit Relocated/moved Other
(Please explain):
Employer 5:
Job title:
Job duties:
Did you have any difficulties with these duties because of your disability? Yes No
If yes, how?
Start date:
End date:
Last salary/pay rate:
Full time
Part time
Reason for leaving: Terminated Laid off Quit Relocated/moved Other
(Please explain):
Counselor notes:
Page 5 of 10 DHS 1277 (10/2016)
Employment
Are you a veteran? Yes No Were you injured during your service? Yes No
Are you receiving services from Veteran Affairs Vocational Rehabilitation? Yes No
Have you ever had a workers’ compensation claim? Yes No Pending
If yes, what state?
Are you a preferred worker in Oregon? Yes No
Disability information
Please list your health conditions/disability(ies)/diagnosis(es) (physical, mental or emotional) in the
order it most affects you.
Condition: Year of onset How it affects me:
1.
2.
3.
4.
5.
Please list any medications that you are currently taking for any of the conditions listed above:
Medication: Purpose:
1.
2.
3.
4.
5.
Counselor notes:
Page 6 of 10 DHS 1277 (10/2016)
Special programs
(check all that you are involved with)
Adult Education and Literacy Programs
Adult Parole/Probation
Alcohol and Drug
Alcohol and Drug — Youth
American Indian VR Services Program
Career Workforce Skills Training
Center for Independent Living
Child Protective Services
Community Rehabilitation Program
Consumer Organization or Advocacy Group
DD Brokerage
DD County Case Management
DOL Employment and Training
Service Programs
Educational Institution
(elementary/secondary)
Educational Institution (post-secondary)
Employed Persons with Disability
Employer
Employment Network (not otherwise listed)
Employment Transition Services
Experience Works
Federal Student Aid (pell grant, SEOG,
work study, etc.)
General assistance
Independent Living Services
Intellectual and Developmental
Disabilities Agency
Juvenile Parole/Probation
Latino Connection-Easter Seals
Medical Health Provider (public or private)
Mental Health Provider (public or private)
One-Stop Employment/Training Center
Other State Agency
Other VR State Agency
Public Housing Authority
School — not Youth Transition Program (YTP)
Schools Youth Transition Program
Seasonal Farm Workers (SFW)
SSA (Disability Determination Service or
district office)
State Department of Correction/
Juvenile Justice
State Employment Service Agency
Supported Employment
Temp Assistance to Needy Families (TANF)
Veterans Administration
Welfare Agency (state or local government)
Work Readiness Workshops
Workers’ Compensation
Workers’ Compensation (special fund)
None
Please list any and all other agencies and organizations that you are currently involved with
(Self-Sufficiency, Adults and People with Disabilities, Mental Health, etc.):
Name of agency: Contact person: Phone number:
Page 7 of 10 DHS 1277 (10/2016)
Counselor notes (counselor see application section, page two, for benefits information):
Additional information
What services do you think you might need from Vocational Rehabilitation to be successful at assisting
you to get to or back to work? (check all that apply.)
Learn how to look for and find work Help to decide a work goal
Learn how to work with my disability Other
(Please explain):
What strengths or skills have you identified about yourself?
Counselor notes:
What type(s) of work are you interested in doing?
Part time-hours per week: Full time Not sure
What is your current level of computer skills/knowledge?
What is your source of transportation? Bus Car Bike Other
Do you possess a valid driver’s license? Yes No Insurance Yes No
If yes, what state:
Page 8 of 10 DHS 1277 (10/2016)
Additional information
Do you have a clean driving record? Yes No If no, please explain:
Have you ever been arrested or convicted of a felony or a misdemeanor? Yes No
If yes, please explain:
Are you currently on supervision of any type? Yes No
If yes, and you are actively supervised, please list name and phone number of
probation/parole officer:
Name: Phone:
Counselor notes:
Do you have any other current legal issues/problems? (specify):
Do you have any history of substance use or abuse? Yes No If yes, please explain:
Could you pass a drug test? Yes No If no, please explain:
Counselor notes:
Education information
Are you a high school graduate or do you have a GED? Yes No
If not, what is the highest grade you completed:
Were you in special education classes while in school? Yes No
Did you have an Individualized Education Program (IEP)? Yes No
Do you have a 504 Plan? Yes No
Were you a participant in the youth in transition program? Yes No
If yes, to any of the above questions, please indicate school name, city and state:
School name City State
Page 9 of 10 DHS 1277 (10/2016)
Education information
If you attended any college/trade school or other trainings:
School name Begin date End date Degree/certification or area of study
A
re you currently attending college? Yes No
If yes, where do you attend college?
Are you currently in default on any prior student loans? Yes No
Counselor notes:
Medical information
Have you ever had a head injury or been knocked unconscious? Yes No
If yes, please explain:
Do you have any restrictions from your doctor about working? Yes No
Counselor notes:
Medical providers
Vocational Rehabilitation (VR) will need your help to get your medical records. We need them to
document your medical condition(s); identify your limitations; determine if you are eligible
for our program; plan work goals; and identify services you may need to help you get or keep
a job. If there is not enough space, list additional providers on a separate piece of paper.
Please list all doctors, clinics, counselors or therapists you have seen in the past or are seeing now
for treatment related to your disability. Include any physical exams and/or learning disability testing.
Medical provider/clinic name:
Phone number:
Address:
Treatment for:
Are you still seeing this provider? Yes No
Most recent visit:
Page 10 of 10 DHS 1277 (10/2016)
Medical information
Medical provider/clinic name:
Phone number:
Address:
Treatment for:
Are you still seeing this provider? Yes No
Most recent visit:
Medical provider/clinic name:
Phone number:
Address:
Treatment for:
Are you still seeing this provider? Yes No
Most recent visit:
Medical provider/clinic name:
Phone number:
Address:
Treatment for:
Are you still seeing this provider? Yes No
Most recent visit:
Medical provider/clinic name:
Phone number:
Address:
Treatment for:
Are you still seeing this provider? Yes No
Most recent visit:
Counselor notes:
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De1277 DHS 1277 Service Questionnaire (Vocational Rehabilitation Services)

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Completed 11 June 2020

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