Application for DVR Services / mong Version (DVR-1-E-H) by bgWro5

VIEWS: 9 PAGES: 5

									Department of Workforce Development                                                                        State of Wisconsin
Division of Vocational Rehabilitation

                                 Daim Ntawv Thov DVR Cov Kev Pab Cuam
                                          (Application for DVR Services)
Tej lus koj qhia txog koj tus kheej yuav tau muab qhia rau lwm lub koom haum muab kev pab cuam [Privacy Law, s. 15.04 (1)(m),
Wisconsin Statutes]. Kev muab koj tus Social Security Number (SSN) yog los ntawm kev yeem xwb; yog hais tias tsis muab ces yuav
ncua sij hawm ntev zog.



Lub Npe                                               Middle Initial                Lub Xeem


Tus Social Security Nab Npawb                         Hnub Yug
      -      -
Chaw Nyob los yog PO Box


Lub Zos                                   Xeev        Tus Zip Code                  Lub Nroog Koj Nyob


Tus Email Address


Tus Xov Tooj                                                     Tus Xov Tooj Ntawm Cev


Koj puas tso cai rau DVR tso lus rau tus xov tooj teev saum toj no?
    Tau                        Tsis Tau

Koj nyiam kom peb tiv tauj koj li cas?
    E-Mail                     Sau Ntawv
    Xov Tooj                   Lwm Yam (Qhia Kom Meej)

Tus Muaj Cai Saib Xyuas Lub Npe (Guardian)                       Tus Muaj Cai Saib Xyuas Tus Xov Tooj


Tus Muaj Cai Saib Xyuas Qhov Chaw Nyob (Lub Koom Haum, Lub Zos, Xeev, Tus Zip Code & Email)


Koj xav kom tau kev pab cuam nyob rau lub nroog twg?




                                                         Page 1 of 5
Xiam Hoob Qhab (khij txhua qhov uas koj muaj)
   AIDS/HIV                                           Quav Dej Cawv los yog Lwm Yam Yeeb Tshuaj
   Amputation (raug txiav tes/taw)                    Arthritis (Mob laug pob qij txha)
   Attention Deficit Disorder                         Autism
   Back Injury (Raug mob nruab qaum)
   Blindness or Visual Impairment (Dig muag los yog Tsis pom kev zoo)
   Brain Injury (Raug hlwb puas)                       Cancer
   Carpal Tunnel (Repetitive Use Syndrome)             Cerebral Palsy (CP)
   Cognitive Disability                                Cystic Fibrosis
   Deaf or Hard of Hearing (Lag ntseg los yog hnov lus tsis zoo)
   Deaf-Blind (Lag ntseg/dig muag)                     Depression (Nyuaj siab ua rau tsis qab siab ua dab tsi)
   Diabetes (Mob ntshav qab zib)                       Epilepsy (Qaug dab peg/mob nriaj tes taw)
   Fibromyalgia                                        Heart Disease (Kab mob plawv)
   Hemophilia
   Hip/Knee/Other Joint Dysfunction (Lub ntsag/Hauv caug/Lwm cov pob qij txha tsis ua hauj lwm zoo)
   Kidney Failure (Raum tsis ua hauj lwm)              Mental Illness (Mob puas siab ntsws tsis meej pem)
   Missing or Deformed Limb (Tsis muaj tes tawv/caj npab los ceg, los yog tsis zoo xib xws)
   Multiple Sclerosis                                  Muscular Dystrophy
   Myofascial Disorder                                 Paraplegia or Quadriplegia
   Post Traumatic Stress Disorder                      Respiratory/Pulmonary/Allergies
   Severe Arthritis (Mob pob qij txha loj heev)        Specific Learning Disability
   Spinal Cord Injury (Raug tus txha qaj qaum sav)     Stroke (Mob ntshav txhaws tuag ib ce)
   Lwm Yam (Qhia Kom Meej                              Tsis Paub (Qhia Kom Meej)

Koj qhov xiam hoob qhab puas yuav muaj kev cuam tshuam rau koj rab peev xwm txog kev ua hauj lwm li cas?




Hom Kev Pab Cuam Koj Xav Tau
   Tus Neeg Txhais Lus ASL (ASL Interpreter)                     Ntaus Cov Ntawv Kom Loj (Large Print)
   Audio Taped Communications (Kaw Cov Lus Sib Tham)             Lwm Hom (Qhia Kom Meej)
   Hom Ntawv Rau Neeg Dig Muag (Braille)                         Lus Spanish
   Lus Hmoob (Hmong)

Lus Hais


Ziag No Ua Num Li Cas (Current Employment Status)
   Ua Num Tsis Tau Kev Pab Ntawm Integrated Setting         Tsis Ua Num – Kawm Ntawv Qib Siab
   Ua Num Tau Kev Pab Ntawm Integrated Setting              Tsis Ua Num – Kawm Ua Num, Ua Hauj Lwm Dawb
   Extended Employment (Workshops)                          Ua Num Rau Kuv Tus Kheej (Except BEP)
   Nyob Hauv Tsev (Homemaker)                               State Agency Business Enterprise (BEP)
   Tsis Ua Num – Kawm Ntawv                                 Ua Num Rau Tsev Neeg Uas Tsis Tau Nyiaj Them
   Tsis Ua Num – Lwm Yam

Yog koj ua num, koj ua num qhob twg?



Koj txoj hauj lwm hu li cas?



                                                   Page 2 of 5
Ib lub lim piam twg koj ua num pes tseg teev?               Ib lub lim piam twg koj tau nyiaj ntau li cas?



Koj puas tau ua num yav dhau los?                           Xyoo Khawg Uas Koj Tau Ua Num
   Ua Num Yav Dhau Los
   Tsis Tau Ua Num Yav Tag Los
Koj hnov txog DVR qhov twg los?
   Community Rehabilitation Programs
   Lwm Qhov (Other Sources)
   Kws Kho Mob, Neeg Ua Hauj Lwm Hauv Tsev Kho Mob, los yog Tsev Kho Mob
   SS Admin. (Ticket to Work / DDS or District Office)
   Tsev Kawm Ntawv - Educational Institutions (Qib 1 txog 12)
   Coj Yus Tus Kheej Tuaj (Self Referral)
   Tsev Kawm Ntawv - Educational Institutions (Qib siab)
   Cov Chaw Muab Kev pab Cuam - Welfare Agency (State or Local Government)
   Chaw Nrhiav Hauj Lwm thiab Qhia Kawm Ua Hauj Lwm (One-Stop Employment/Training Centers)
Poj Niam los yog Txiv Neej
   Txiv Neej
   Poj Niam

Yog Haiv Neeg Twg (khij txhua yam uas yog rau koj)
   Neeg Dawb         Neeg Dub       Neeg Tawv Daj
   American Indian, Native American or Alaska Native        Native Hawaiian or Other Pacific Islander

Haiv Neeg Twg - Koj puas yog neeg Hispanic los yog Latino?
   Yog         Tsis Yog

Muaj Txiv/Poj Niam
   Sib Nrauj Lawm                     Yeej Tsis Tau Sib Yuav Li                Poj Ntsuam
   Muaj Txiv/Poj Niam                 Sib Cais Lawm

Kawm Ntawv Siab Npaum Li Cas
   Tsis Tau Kawm Ntawv                                       Kawm Nyob Qib Siab, Tsis Tiav
   Kawm Qib 1-8                                 Kawm Tiav Associate Degree los yog Vocational/Tech Certificate
   Kawm Qib 9-12, Tsis Tau Diploma                           Kawm Tiav Bachelor's Degree
   Special Education Attend/Certificate of Completion        Kawm Tiav Master's Degree los yog Siab Dua
   Kawm Tiav High School (HS)

Tam sim no koj puas tseem kawm ntawv nyob high school?                 Kawm        Tsis Kawm

Yog kawm, tsev kawm ntawv lub npe?

Koj puas yog ib tug qub tub rog?                  Yog       Tsis Yog




                                                     Page 3 of 5
Tam sim no koj nyob qhov twg?
    Tsev Laj Cuj Kaw Neeg Laus                               Chaw Tu Neeg Muaj Mob Tsis Taus (Nursing Home)
    Community Residential/Group Home                         Lwm Qhov
    Chaw rau neeg nyob Halfway House
    Nyob hauj kuv lub tsev - Private Residence (Independent, Family, etc.)
    Chaw Rau Cov Neeg Tsis Muaj Tsev Nyob (Homeless/Shelter)
    Chaw Pab Kho Neeg Kom Zoo Rov Los Li Qub (Rehabilitation Facility)
    Chaw Rau Neeg Vwm Nyob (Mental Health Facility)
    Chaw Rau Neeg Txiav Yeeb Txiav Tshuaj (Substance Abuse Treatment Facility)

Qhov chaw twg pab nyiaj ntau tshaj plaws rau koj tam sim no? (Xaiv qhov pab nyiaj ntau tshaj plaws.)
    Yus Li Nyiaj (Personal Income) (ua hauj lwm tau, nyiaj paj, dividends, nyiaj xaub tsev)
   Tsev Neeg thiab Phooj Ywg (xws li tus poj niam/tus txiv qhov nyiaj los yog tus poj niam/tus txiv cov nyiaj poob
hauj lwm)
    Kev Pab Cuam Ntawm Tseem Fwv (Public Support) (SSI, SSDI, TANF [xws li, W-2, Kinship Care, Wisconsin
    Shares, Caretaker Supplement], UI, Incarcerated, etc.)
    Lwm Yam Kev Pab (xws li, nyiaj tau los ntawm disability insurance thiab neeg pub (private charities)
Tseem Ceeb Heev:        Thaum xaiv Public Support, tsawg kawg kiag ib qho ntawm qhov Monthly Public Support
                        Amounts hauv qab no yuav tsum ntau dua zero.
Nyiaj pab ntawm tseem fwv Txhua Hli (kom ze rau dollar); koj tau nyiaj pab ntawm cov chaw no ntau npaum li cas?

$           SSI - Supplemental Security Income rau cov neeg Laus, Dig Muag los yog Xiam Hoob Qhab
$           TANF - Temporary Assistance for Needy Families (e.g., W-2, Kinship Care, Wisconsin Shares,
            Caretaker Supplement)
$           General Assistance (e.g., county funds, FoodShare, etc.)

$           SSDI - Social Security Disability Insurance

$           Nyiaj Qub Tub Rog (Veterans Affairs (VA) Disability Benefits)
$           Worker’s Compensation (WC)

$           Lwm Yam Keb Pab – Kev Pab lwm qhov ua tsis tau teev tseg (nyob rau hauv UI)
Ntawv Kho Mob (Medical Insurance)
Medicaid/BadgerCare/MAPP                                     Yes              No
Medicare                                                     Yes              No
Nyiaj Luam Tau Lwm Qhov Los                                  Yes              No
Nyiaj Tau Ntawm Chaw Ua Hauj Lwm Los                         Yes              No
Nyiaj Tau Ntawm Lwm Lub Insurance Los                        Yes              No




                                                    Page 4 of 5
                                 Keeb Kwm Kev Ua Hauj Lwm (Employment History)
                                      (Siv sab nraum qab, yog tsis txaus sau tej keeb kwm)

Chaw Ua Hauj Lwm Lub Npe                            Lub Zos                                  Xeev


Position/Job Title                                               Hnub Ua Hauj Lwm (Hli/Xyoo)


Vim Li Cas Thiaj Tawm


Lub Luag Hauj Lwm


Chaw Ua Hauj Lwm Lub Npe                            Lub Zos                                  Xeev


Position/Job Title                                               Hnub Ua Hauj Lwm (Hli/Xyoo)


Vim Li Cas Thiaj Tawm


Lub Luag Hauj Lwm


Chaw Ua Hauj Lwm Lub Npe                            Lub Zos                                  Xeev


Position/Job Title                                               Hnub Ua Hauj Lwm (Hli/Xyoo)


Vim Li Cas Thiaj Tawm


Lub Luag Hauj Lwm


Tus Neeg Ua Daim Ntawv Thov Kos Lub Npe (los yog Tus Guardian Koj Nws                         Hnub Kos Npe
Lub Npe yog Tsis tau Muaj 18 Xyoo los yog rau xaiv los ntawm tsev hais plaub)




                                                   For DVR Office Use Only

Hnub Tau Txais                                                   DVR Tus Neeg Ua Hauj Lwm



DWD yog ib qhov chaw ua hauj lwm muab kev pab mauj vaj huam sib luag. Yog koj xiam hoob qha es xav tau kev
pab kom muab cov ntaub ntawv no txhais ua lwm hom, los yog txhais ua lwm hom lus, thov hu rau tus xov tooj 800-
442-3477 los yog 888-877-5939 (TTY).

DVR-1-E-H (R. 05/2012) (T. 05/2012)



                                                          Page 5 of 5

								
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