STATE OF CALIFORNIA DEPARTMENT OF REHABILITATION

VOCATIONAL REHABILITATION SERVICES APPLICATION

DR 222 (REGS/Rev. 03/04)

Privacy Statement: The Information Practices Act of 1977 (Civil Code Section 1798.17) and the Federal Privacy Act (5 USC 552a(e)(3)) require this notice to be provided to individuals when collecting personal information. The information requested on this form, including the Social Security Number, is necessary to properly identify the individual to ensure that the Department provides services to the correct individual. Failure to provide the information requested may result in delays in services. Department authority: Welfare & Institutions Code Sec. 19005, 19005.1, 19010.

Last Name

Other Name(s) Used

First Name

Middle Initial

Street Address

Mailing Address If Different

City

Zip Code

County

Telephone Number

Social Security Number

Age

Date Of Birth

Driver's License/I.D. Number

Please describe your physical or mental impairment which constitutes or results in a substantial impediment to employment.

How can we help you?

Who referred you?

Full name of person not in your home who will always know where you live:

Address

City

Phone Number

Relationship

RELEASE OF INFORMATION TO PROSPECTIVE EMPLOYERS: I hereby authorize the Department of Rehabilitation to release information (except medical and psychological) to prospective employers for the purpose of assisting me in job placement. I understand that only information necessary to assist me in job placement will be released. This consent applies until such time as my case is closed or I specifically withdraw my consent. YES NO

ORIENTATION MATERIALS: I have received & read my "Client Information Booklet" and have discussed with my Counselor: Civil Rights, Eligibility Requirements, Informed Choice, Confidentiality, Appeals Procedures, and the Client Assistance Program (CAP). YES NO

The Immigration Reform and Control Act of 1986, states employers should only hire American citizens and aliens who are authorized to work in the United States. To verify your employment eligibility, please check box below. This does not replace requirements of employers as specified under the Immigration Reform and Control Act of 1986.

I am: 1. A citizen or national of the United States.

2. An alien lawfully admitted for permanent residence (Alien Number A ________________).

3. An alien authorized by the Immigration and Naturalization Service to work in the United States

(Alien Number A ________________ or Admission Number _______________, expiration of

employment authorization, if any _________).

4. None of the above.

SEE REVERSE FOR YOUR APPEAL RIGHTS INFORMATION AND HOW TO CONTACT YOUR CAP ADVOCATE.

Applicant's Signature ?		Date Signed		Parent/Guardian's Signature (required for minor) ?
TO BE COMPLETED BY COUNSELOR
Counselor's Signature ?	Date Signed		Counselor's Name (Printed)		Counselor's Phone Number

DISTRIBUTION: Original (Pink) - Case Folder Copy (White) – Applicant

STATE OF CALIFORNIA DEPARTMENT OF REHABILITATION

VOCATIONAL REHABILITATION SERVICES APPLICATION - ATTACHMENT

DR 1000 (Rev. 10/07)

YOUR RIGHTS AND REMEDIES REGARDING YOUR REHABILITATION PROGRAM

If questions or problems arise while you are an applicant or client of the Department of Rehabilitation, please talk with your Rehabilitation Counselor and/or call the Client Assistance Program (CAP). You may bring a family member or other representative with you any time you meet with Department staff.

If you are dissatisfied with any action or decision of the Department, you have the right to speak to a Rehabilitation Supervisor, have an Administrative Review by the District Administrator, or file a formal request for a mediation and/or Fair Hearing. In fact, you can always file for a mediation and/or Fair Hearing at any time; however, many problems can be resolved informally and more quickly at the local level.

You have the right to take any of the following steps should issues arise:

COUNSELOR Many misunderstandings and problems can be solved by talking them over with your Rehabilitation Counselor. Sometimes your counselor may not know that a problem exists. It is your responsibility to tell him or her.

SUPERVISOR If you believe that you and your counselor cannot resolve the issue, you may ask for a meeting with your counselor's supervisor to discuss the problem.

ADMINISTRATIVE REVIEW If the issue is not resolved with the Rehabilitation Supervisor, you may request an Administrative Review by the District Administrator. The Administrative Review must be requested within one year of the decision with which you disagree. If the issue is still not resolved at this level, you may request a mediation and/or Fair Hearing within 30 days.

MEDIATION You may request confidential mediation at any time within one year of the action or decision with which you disagree. If you and the Department representatives are not able to resolve the issue directly, a qualified, impartial mediator can help you find solutions that are satisfactory for both of you. If the Department agrees to mediate, a mediation will be held within 25 calendar days from receipt of your request, unless you agree to a later date. Request for Mediation forms are available from Department staff and/or CAP advocates. A written request or completed request form (DR107) should be mailed to the DOR Mediation Coordinator, Office of Administrative Hearings, 2349 Gateway Oaks Drive, Suite 200, Sacramento, CA 95833 (Voice 916-263-0654) or faxed to 916-376-6318 or 916-263-0549. TTY users may call 711 and give the California Relay Service (CRS) operator the mediation office phone number. The CRS operator will then connect and relay the call. Requests for mediation may also be made at the same time a request for Fair Hearing is filed with the Rehabilitation Appeals Board.

FAIR HEARING At any time within one year of the action or decision with which you disagree (within 30 days if you had an administrative review) you may request a Fair Hearing. This is your opportunity to present your case to the Rehabilitation Appeals Board. The Board is composed of seven members who are citizens from the community, appointed by the Governor. At the hearing, you have the right to present information to the Board, explaining why you feel the Department should change a decision it has made. The Department of Rehabilitation is also allowed to provide information to the Board. After the hearing, a written, final decision will be made by the Board. Requests for Fair Hearing forms are available from Department staff and/or CAP advocates. Completed request forms should be sent to Rehabilitation Appeals Board, Department of Rehabilitation, P.O. Box 944222, Sacramento, CA 94244-2220 (Voice 916-558-5860 or TTY 916-558-5862).

The Fair Hearing will be scheduled within 45 days of your request, unless you agree to a delay. You may appear at the hearing in person or have the matter heard on the written record. If the Fair Hearing decision does not satisfy you, you have the right to file a petition with the California Superior Court (within six months) to review the matter.

DISCRIMINATION If you have reason to believe that actions or decisions were based on discrimination against your protected status, such as race, religion, sex, etc., you have the right to contact the Department's Office of Civil Rights and Affirmative Action for discrimination counseling or to file a discrimination complaint. Assistance regarding discrimination concerns can be obtained from the Office of Civil Rights and Affirmative Action by calling Voice 916-558-5850 or TTY 916-558-5852.

CLIENT ASSISTANCE PROGRAM The Client Assistance Program may be available to assist you during the entire rehabilitation and appeals processes. You can call them toll free at Voice 800-952-5544 or TTY 866-712-1085.