(a)  The Division utilizes the forms specified in this Rule in its administration of the vocational rehabilitation program.  Copies of the forms are available to the public upon written request to:

APA Coordinator

Division of Vocational Rehabilitation Services

805 Ruggles Drive

2801 Mail Service Center

Raleigh, North Carolina 27699-2801.

(b)  Client Data Sheet.  This form collects basic demographic information on the client (name, address, referral source, age, sex, social security number, public assistance status, etc.) as well as outlining the services being provided by the Division and the actions taken by the Division.  This is the primary form used for initiating and updating the client data information with primary utilization being to meet the federal reporting requirements.

(c)  Authorization of Services.  This form is completed, forwarded to a vendor of services, and gives the vendor agency approval for the initiation of services.

(d)  General Basic Medical Examination Record.  This form is utilized to collect a record of the client or applicant's general health status and to meet federal requirements for such.  It is completed by a medical doctor and becomes part of the client's record.  The Division also utilizes, to some degree, variations of this basic form to provide specialty reports on specific disability types:

(1)           Medical Report Cardiac Disability,

(2)           Medical Report Visual Disability,

(3)           Medical Report Hearing Disability,

(4)           Physician's Report, and

(5)           Report of Dental Examination.

(e)  Survey Interview.  This form is the basic intake document of the Division and collects from the client or applicant basic demographic data (e.g., name, address, telephone, age, referral source, family information, earnings, vocational history, medical history, disability, military record, court record, etc.).  The form is signed by the applicant or the applicant's guardian if the applicant is under age 18.

(f)  Financial Statement.  This form is utilized by the counselor to plan with the client the cost responsibility for certain services and to determine the extent to which client resources can be used in meeting the cost of the rehabilitation program.

(g)  Certificate of Ineligibility.  This form is directed to applicants or clients and advises them that they do not meet or no longer meet the criteria of eligibility for services.  It also advises these individuals of their rights and remedies and the steps they should take to request an administrative review or hearing.  It also states the Division's policy on nondiscrimination.

(h)  Certificate of Eligibility.  This form is directed to applicants or clients and advises them that they do meet the criteria of eligibility.  It also advises them of the Division's policy on nondiscrimination.

(i)  Individualized Written Rehabilitation Program.  This form is directed to the eligible client and outlines the respective client's individualized rehabilitation program.  It contains information regarding the types of services needed by the client to go to work, the objectives of the specific services, the evaluation criteria to measure success, the date to begin and complete the services, the client's eligibility for any comparable benefits, and the client's views of the program.  The form also advises clients of their rights and remedies, their responsibilities, confidentiality, and annual progress review responsibilities.  The form described in Paragraph (j) of this Rule is a continuation of this form.

(j)  Addendum to the Individualized Written Rehabilitation Program. This form has several primary uses, including being a general utility, multi‑purpose form.  The primary use is to provide a mechanism for amending the individualized written rehabilitation program and keeping the client informed of the amendments.  Other uses include the documentation of case closure, progress reports, post‑employment services, review of ineligibility determinations, and annual reviews.


History Note:        Authority G.S. 143‑546; 150B‑11(1);

Eff. February 1, 1976;

Amended Eff. May 1, 1990; October 20, 1979;

Pursuant to G.S. 150B-21.3A rule is necessary without substantive public interest Eff. March 1, 2016.