FORMS

Business Enterprises Program

• DR 462 - Vending Facility Application (PDF)

Community Rehabilitation Program

• DR 401 CRP Certification and Vendorization Application (PDF)

Fair Hearing Forms and Related Documents

• DR 107 - Request for Mediation and/or Fair Hearing (PDF)

• DR 108 - Authorized Representative (PDF)

• DR 1000 - Rights and Remedies (PDF)

• DR 135 - Formal Complaint of Discrimination (PDF)

Health Care Provider

• DR 361 - Health Care Provider Application (PDF)

• STD 204 - Payee Data Record (PDF)

Individual Service Providers (ISP)

• DR 171 - ISP Application (PDF)

• STD 204 - Payee Data Record (PDF)

• DR 296 - ISP Invoice (PDF)

• DR 296A - Worksheet (PDF)

• DR 174 - Progress Report (PDF)

Student Services

• DR 203 - Student Services Plan Request (PDF)

• DR 205 - Student Services Plan (PDF)

Supported Employment

• DR 381 - Job Placement Parameters Sample Form (PDF)

• DR 382 - Placement Services Progress Report (PDF)

• DR 383 - Job Placement Information (PDF)

• DR 384 - Supported Employment - Monthly Job Coach Report (Excel)

• DR 384A - Proposed Plan to Improve Performance (PDF)

• DR 385A - Individual Invoice Summary (PDF)

• DR 385B - Individual Invoice Detail (PDF)

• DR 385C - Group Invoice Summary (PDF)

• DR 385D - Group Invoice Detail (Word)

• DR 385E - Group Job Coaching Invoice Detail (Word)

• DR 386 - Invoice Discrepancy Notice Sample Form (PDF)

• DR 387 - Notice of Transition to Extended Services Sample Form (PDF)

• Department of Developmental Services Habilitation SEP/WAP Work Services Forms including:

  • DS 1964 - Supported Employment Group Billing and Attendance Form (Group Placement) completed by vendors.
  • DS 1968 - Vocational Rehabilitation Referral completed by regional centers

Vocational Rehabilitation

• DR 222 - Vocational Rehabilitation Services Application (PDF)