Received: __________________________
By: _______________________________
Contact Date: _______________________
Phone: _______ Letter ____In Person____
Appt. Scheduled: ____________________

FLORIDA DEPARTMENT OF EDUCATION
DIVISION OF VOCATIONAL REHABILITATION 
REFERRAL/APPLICATION FOR VOCATIONAL REHABILITATION SERVICES

I am a person with a mental or physical impairment that interferes with my ability to work.  I want to learn more about the rehabilitation services available through the Division of Vocational Rehabilitation and how they can assist in securing or retaining employment.  

Name:        
Social Security Number:       				Date of Request:	current date
Address:       	City, State Zip:      ,              
Date of Birth:       		Sex:       
Marital Status:        	Race:         	Education Level:      
Telephone number where you can be reached:            
Or email address (if preferred):      
Name of a contact person:      
Telephone number of the contact person:            
What is the best method to contact you?      
What impairment prevents you from working:      
Do you require American Sign Language interpreter?	  Yes 
Do you require assistive listening device? 		  Yes
Do you require a foreign language interpreter? 		  Yes  If so, which language:      
Do you require translated documents? 			  Yes
Do you require any accommodation for your impairment?  Yes 
If yes, please explain:      
If referral is by an agency or other person:
Name: 	     
Address of Agency or Person 	     
City, State, Zip-Code:		     ,            
Telephone Number:		            
--------------------------------------------------------------------------------------------------------------------------------------------
(Your signature, or that of your parent or guardian, completes the application process 
for Vocational Rehabilitation.  You may request additional information 
or speak with a counselor to get information prior to application.)

I understand that the purpose of receiving vocational rehabilitation services is to enable me to retain or secure employment.  I understand that I must be found eligible for the services that I require.  I am applying for vocational rehabilitation services and wish to undergo an assessment of my eligibility.

				current date	
Signature of Applicant		Date of Application	

Signature of Parent or Guardian			

Please mail or turn in your application to the nearest VR office.
For a list of offices, go to: www.rehabworks.org and then click on:
“Contact Us” and then select “Directory of Local VR Offices and Vendors”

OR

You may call our toll free number 1-800-451-4327 for more information.

Florida Department of Education Division of Vocational Rehabilitation
Social Security Number Collection Policy
 
In compliance with Section 119.071(5), Florida Statutes, this statement serves to notify you of the purpose for the collection and usage of your social security number by the Florida Department of Education, Division of Vocational Rehabilitation (“Division”).
 
The Division is authorized by federal and state law to collect social security numbers in determining individuals’ eligibility for vocational rehabilitation services, and such collection is imperative for the performance of the Division’s duties. 

Information about Discrimination

It is against the law for the Division of Vocational Rehabilitation (VR) of the Florida Department of Education, as a recipient of Federal financial assistance, to discriminate against any individual in the United States on the basis of race, color, religion, sex, national origin, age, disability, political affiliation or belief.

The application process used by VR to determine eligibility for services, any subsequent services, and the entire VR process are subject to these non-discrimination requirements.

What to Do If You Believe You Have Experienced Discrimination

If you think that you have been subjected to discrimination under a federally assisted program administered by the Division of Vocational Rehabilitation, you may file a complaint within 180 days from the date of the alleged violation with:

U.S. Department of Education
Office for Civil Rights (OCR)
Atlanta Office
61 Forsyth Street, Suite 19T10
Atlanta, Georgia 30303-8927
Phone: (800) 421-3481
TDD: (800) 877-8339
email:  OCR.Atlanta@ed.gov