Article Structure
The VR 04 form serves as a critical step for individuals seeking vocational rehabilitation services in New York State. Primarily, this application, managed by the Office of Adult Career and Continuing Education Services-Vocational Rehabilitation (ACCES-VR), collects essential personal information, including the applicant's name, gender, and contact details. The form requires applicants to disclose significant data such as their Social Security number and date of birth, which assists ACCES-VR in processing their application efficiently. Understanding the applicant’s background is also vital; therefore, various fields address race and ethnicity, disability details, and prior services received from ACCES-VR or its predecessor, the Office of Vocational and Educational Services for Individuals with Disabilities (VESID). Moreover, the form explores the applicant’s work history and current support services, which allow ACCES-VR to tailor services effectively. Key elements also include information about the applicant’s educational background and living situations. Completing the VR 04 form accurately can lead to necessary vocational rehabilitation services, promoting an individual’s ability to work despite disabilities.
Vr 04 Example
Please return the completed form to: |
The University of the State of New York |
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THE STATE EDUCATION DEPARTMENT |
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Office of Adult Career and Continuing |
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Education |
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Application for VR Services |
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Please print or type all entries
NAME |
Last |
First |
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Middle Initial |
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If you have been known by another name, enter here: |
Last |
First |
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GENDER
Male
Female
Middle Initial
HOME ADDRESS Street |
Apartment Number |
City |
State |
Zip +4 Code |
County |
SOCIAL SECURITY NUMBER
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If your MAILING ADDRESS is different than your home address, please complete the mailing address information below.
MAILING ADDRESS |
Street |
Apartment Number |
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City |
State |
Zip +4 Code |
County |
PHONE NUMBER(S) where we can reach you or leave a message:
Area code |
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Area code |
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Home |
Cell |
Other |
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Cell |
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Email:______________________________________
Best time to call 1.
2.
DATE OF BIRTH
Month Day Year
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American Indian or Alaska Native
Asian (includes Indian Subcontinent) 
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
What is your disability? |
Who referred you to us? |
MARITAL STATUS: (Check Box) |
Married Widowed Divorced
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Separated |
Never Married |
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I hereby apply for rehabilitation services: |
Signature of applicant, parent, or legal guardian. |
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Date________________ |
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X (Sign here.)
Please answer the questions below and on the back of this form.
You do not have to answer these questions now, but your answers will help
Have you ever received services from
Individuals with Disabilities (VESID)? |
Yes |
No |
Are you now receiving services from one or more agencies? ………………………………………. |
Yes |
No |
If you answered yes, indicate agency names(s), address(es) and contact person(s): |
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Describe how your disability limits your ability to work. |
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What services are you seeking from
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Are you disabled because of a |
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Are you a veteran? |
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Do you use any assistive devices or aids? |
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No |
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Are you a citizen of the United States? |
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Do you have a NYS driver’s license? |
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Do you have a driver’s license from a state other than New York? |
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If no, are you legally permitted to work in |
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Do you have Access to a motor vehicle? |
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this country? |
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Do you use public transportation? |
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Check the benefits you now receive: |
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SSI |
SSDI |
Workers Compensation |
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Are you able to leave your home? |
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Other, specify ______________ |
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Do you regularly see a doctor or clinic about your disability? |
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No If yes, indicate date of last visit: ___________ |
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Please provide the name and address of doctor(s) and clinic(s): |
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List the highest grade you have successfully completed: ___________ |
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and check the applicable box(es) |
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___College |
____Graduate School |
___Doctorate |
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GED or High School Equivalency Diploma |
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Special Education |
Yes No Do you now attend high school? |
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Indicate college degree(s) earned: |
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Name and address of school you last attended: |
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List below other people in your household |
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Full Name |
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Age |
Their Relationship to You |
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List below the people
Name
Address
Phone
List below your work history (include attachments for additional Jobs, if necessary)
Employer Name and Address
Dates Employed From - To
Weekly Earnings
Job Title and Duties, and Reason for Leaving
Persons applying for or receiving rehabilitation services have the right to have any actions or decisions of this Office reviewed. A description of the review process and form can be obtained from any
All information will be kept confidential and is subject to verification.
The State Education Department does not discriminate on the basis of age, color, religion, creed, disability, marital status, pregnancy, veteran status, national origin, race, gender, genetic predisposition or carrier status, or sexual orientation in its recruitment, educational programs, services, and activities. Portions of any publication designed for distribution can be made available in a variety of formats, including Braille, large print or audiotape, upon request. Inquiries regarding this policy of nondiscrimination should be directed to the Office of Human Resources Management , Room 528 EB, Education Building, Albany, NY 12234. Request for publications should be made to the Department’s Publications Sales Desk, Room 309, Education Building, Albany, NY 12234.
Form Characteristics
| Fact Name | Description |
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| Form Purpose | The VR-04 form is an application for vocational rehabilitation services provided by ACCES-VR, aiming to assist individuals with disabilities in achieving employment. |
| Governing Law | This form is governed by New York State laws, particularly those related to vocational rehabilitation and services for individuals with disabilities under the New York State Education Department. |
| Confidentiality Assurance | All information provided on the VR-04 form is kept confidential and is subject to verification to protect applicants' privacy. |
| Non-Discrimination Policy | The form complies with New York's non-discrimination policy, ensuring services are provided regardless of age, race, gender, or disability status. |
Guidelines on Utilizing Vr 04
Once you have gathered all the necessary information, you are ready to complete the VR-04 form. This application will help initiate the process for receiving vocational rehabilitation services. Make sure to provide accurate and complete information to avoid any delays.
- Personal Information: Begin by filling in your full name—last name, first name, and middle initial. If you have had another name, provide that as well.
- Gender: Indicate your gender by checking the appropriate box (Male or Female).
- Home Address: Fill in your street address, apartment number (if any), city, state, zip code, and county.
- Social Security Number: Enter your social security number in the designated space.
- Mailing Address: If your mailing address differs from your home address, provide the necessary details including street, apartment number (if any), city, state, zip code, and county.
- Phone Numbers: List at least one phone number where you can be reached. Include area codes.
- Email: Provide your email address for communication.
- Best Time to Call: Indicate your preferred times for someone to reach you.
- Date of Birth: Fill in your date of birth in the provided format (Month, Day, Year).
- Race/Ethnicity: Choose all racial/ethnic categories that apply to you. If Hispanic or Latino is checked, take additional action as instructed on the form.
- Disability: Describe your disability briefly.
- Referral Source: Note who referred you to ACCES-VR.
- Marital Status: Check the box that corresponds to your marital status.
- Signature: Sign and date the form at the bottom, involving your parent or legal guardian if necessary.
After completing the required sections, move on to the questions at the end of the form. Answer as many as you can, but remember you can leave some blank if you prefer. Your insights will assist ACCES-VR in processing your application effectively. Finally, be prepared to submit the completed form to the address provided.
What You Should Know About This Form
What is the VR-04 form used for?
The VR-04 form is an application for vocational rehabilitation services provided by the New York State Education Department’s Office of Adult Career and Continuing Education Services. Individuals with disabilities can use this form to request help in obtaining services that support employment and career opportunities.
Who should fill out the VR-04 form?
This form should be filled out by individuals seeking vocational rehabilitation services due to a disability. Whether you are looking for assistance for the first time or have received services before, this application is essential for accessing potential support.
What information is required on the VR-04 form?
Applicants must provide personal details, including name, address, and contact information. Additionally, you will need to disclose your disability, referral sources, and any current services you are receiving. Information about your education and work history will also be necessary. Only complete the optional questions if you feel comfortable, as they help ACCES-VR process your application more efficiently.
Where should I send my completed VR-04 form?
Your completed VR-04 form should be mailed to the University of the State of New York, specifically to the Office of Adult Career and Continuing Education Services-Vocational Rehabilitation (ACCES-VR). Make sure to check the mailing address on the form for accuracy before sending it.
How long does it take to process the VR-04 form?
The processing time can vary depending on the volume of applications received and the completeness of your submission. However, once your application is received, ACCES-VR will typically contact you within a few weeks to discuss the next steps in your application process.
Can I get help with filling out the VR-04 form?
Yes, assistance is available if you need help completing the VR-04 form. You can reach out to local ACCES-VR offices, community organizations, or support services that specialize in vocational rehabilitation. They can guide you through the application process and answer any questions you may have.
Common mistakes
When filling out the VR-04 form, it’s crucial to avoid common mistakes that can delay your application process. One frequent error is neglecting to provide a complete name. Make sure to fill in your last name, first name, and middle initial. If you’ve used a different name in the past, include that as well. Skipping this information can create confusion and slow down your application.
Another common oversight is not including the social security number. This number is essential for processing your application. Ensure that the number is accurate and clearly written. Also, be careful to confirm that your mailing address matches your home address unless they differ; this needs to be indicated in the separate mailing section.
Many applicants accidentally leave sections blank, particularly in the race/ethnicity and disability areas. If these sections are left empty, ACCES will fill them in for you, which might not reflect your accurate identity or needs. Take the time to complete these sections thoughtfully.
Completing the phone number section is often overlooked. Always provide at least one phone number where you can be reached, and indicate the best times to contact you. This makes it easy for ACCES-VR to reach you regarding your application. You may also want to verify the area codes to ensure accuracy.
Many individuals misunderstand the importance of detailing their disability. A vague description might not effectively communicate your situation. Provide a clear account of how your disability affects your ability to work, which helps ACCES-VR tailor its services to your needs.
Some applicants also forget to check off marital status. This information is vital for understanding your situation and needs. Ensure that this section accurately reflects your current status.
Applicants sometimes skip the section regarding previous services received from ACCES-VR or its former name. It’s important to answer this question accurately. This information can help your application go through more smoothly.
Don’t forget to review the education section thoroughly. Listing the highest grade completed is essential, as is providing information about any college degrees earned. Double-check the name and address of the school you last attended; making errors here can lead to confusion.
Lastly, people often forget to provide contact information for alternative contacts. Giving names and addresses of people ACCES-VR can reach if they are unable to contact you helps prevent delays and ensures that your application continues to move along smoothly.
Documents used along the form
The VR-04 form is an essential document for individuals seeking vocational rehabilitation services in New York. It gathers crucial information about the applicant's background, disability, and needs. Alongside this form, several other documents may be required to facilitate the application process. Below are four such documents that are often utilized with the VR-04 form.
- Medical Documentation: This establishes the applicant's disability and may include evaluations, treatment summaries, or letters from healthcare providers outlining the individual’s capabilities and limitations.
- Proof of Income: Documents such as pay stubs, tax returns, or benefit statements clarify the applicant’s financial status. This information helps assess eligibility for certain services and determine the level of support needed.
- Educational Records: High school diplomas, transcripts, or vocational training certificates may be needed. These documents help evaluate the applicant's educational background and assist in creating a tailored rehabilitation plan.
- Referral Letter: A letter from a healthcare provider, social worker, or other professional may accompany the VR-04 form. This letter typically provides context regarding the applicant’s situation and the services being requested.
Providing these documents along with the VR-04 form can streamline the application process and improve the chances of receiving the necessary rehabilitation services. Ensure all paperwork is accurate and complete before submission for optimal processing.
Similar forms
The VR-04 form is essential for individuals seeking vocational rehabilitation services. Several other documents share similarities with the VR-04 form. Here is a list of those documents and how they are related:
- Application for Social Security Disability Insurance (SSDI): Like the VR-04, this application gathers personal and medical information to determine eligibility for assistance due to disability.
- Supplemental Security Income (SSI) Application: Similar to the VR-04, this document seeks detailed information about an individual's financial and disability status to assess eligibility for financial support.
- Employment Authorization Document (EAD) Application: This application requires personal details to establish eligibility for working in the U.S., akin to the VR-04 collecting work-related information from applicants.
- Rehabilitation Services Administration (RSA) Application: Much like the VR-04, the RSA application seeks to understand the applicant's background and disability to deliver appropriate services.
- Medicaid Application: This document gathers personal and health-related information similar to the VR-04, focusing on healthcare assistance eligibility.
- State Unemployment Insurance Application: This form collects employment history and personal information, paralleling the VR-04's emphasis on work history and disability-related inquiries.
Dos and Don'ts
When filling out the VR-04 form, it is essential to pay attention to specific guidelines to ensure the process goes smoothly. Below is a list of things you should and shouldn't do:
- Do: Print or type all entries clearly.
- Do: Double-check your contact details for accuracy.
- Do: Provide complete information about your disability.
- Do: Indicate your preferred contact times for any follow-up calls.
- Do: Read the entire form thoroughly before submission.
- Don't: Leave any required sections blank unless specified.
- Don't: Use abbreviations that could lead to confusion.
- Don't: Forget to sign the application where indicated.
- Don't: Submit the form without reviewing all of your responses.
- Don't: Provide false information, as it may affect your application.
Misconceptions
Misconceptions about the VR-04 form can lead to confusion and delays in receiving services. Here are five common misconceptions, along with explanations to clarify the facts:
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Misconception: The VR-04 form is only for first-time applicants.
This form can be used by both first-time applicants and those who have received services in the past. If you have previously worked with ACCES-VR or its former name, VESID, you should still complete the VR-04 to ensure your information is updated.
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Misconception: You must answer all questions on the form immediately.
While your answers are helpful, you do not need to complete every question right away. You can leave certain questions blank for now and provide answers later, as long as you ensure the essential information is filled in for processing your application.
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Misconception: Providing a Social Security number is optional.
The Social Security number is required on the VR-04 form. This information helps ACCES-VR verify your identity and eligibility for services, so it’s important to include it accurately.
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Misconception: The form is only for individuals with visible disabilities.
The VR-04 is intended for anyone with a disability, whether visible or not. It is important to describe any limitations your disability may present in the workplace, regardless of whether those limitations are noticeable to others.
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Misconception: Only people in specific professions can receive assistance from ACCES-VR.
ACCES-VR services are available to a wide range of individuals from various professional backgrounds and levels of education. Whether you are seeking assistance for vocational training, job placement, or other rehabilitation services, the program is designed for diverse participants.
Key takeaways
Filling out the VR 04 form can seem daunting, but it’s essential for accessing vital vocational rehabilitation services. Here are some key takeaways to help you navigate the process with ease:
- Complete All Sections: Ensure every section of the form is filled out completely. Missing information can delay processing and may require you to resubmit.
- Use Clear Print: Whether you’re printing or typing, clarity is key. Make sure your handwriting is legible or that your typed answers are easy to read.
- Be Accurate With Personal Information: Double-check that your name, address, and social security number are accurate. Any discrepancy can lead to complications.
- Explain Your Disability: Provide a detailed description of your disability. The more information you share, the better ACCES-VR can assist you.
- Include Referral Information: If someone referred you to ACCES-VR, mention their name. This can help streamline your application process.
- Provide Contact Information: List reliable contact methods. Include phone numbers and a preferred email address so that ACCES-VR can reach you easily.
- Submit Promptly: Once completed, return your form to the specified address. Prompt submission means you can begin receiving services sooner.
Following these steps can help ensure a smoother application process. Remember, the goal of the VR 04 form is to connect you with services that can aid in your rehabilitation journey.
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