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Case Services

Form Name Action Form Owner Revision Date Notes
Application/Sources & Services - Spanish Print
Angela Fujan 10/31/2017 Revised Spanish Application with Sources & Services page.
Application/Sources & Services - English Order
Data Entry
Angela Fujan 10/31/2017 Revised Application has addition of Sources & Services form
Communication Assessment Print
Data Entry
Angela Fujan 08/31/2016
Employment Discussion & Job Planning Discussion Guides Order
Angela Fujan 05/04/2016
IL Assessment-Barriers to Employment Print
Carla Lasley 07/31/2008
IL Assessment-Household, Relocation, Cleaning Print
Carla Lasley
IL Assessment-Menu Planning/Prep, Laundry/Clothing Care, Daycare Print
Carla Lasley 07/31/2008
IL Assessment-Rehab Engineering & Assistive Tech Print
Carla Lasley 07/31/2008
IL Assessment-School Needs Print
Carla Lasley 07/31/2008
IL Assessment-Transportation, Health & Hygiene Print
Carla Lasley 07/31/2008
IL Assessment-Work-Site Needs/Accommodations Print
Carla Lasley 07/31/2008
Physical Capacities Print
Data Entry
Angela Fujan 02/28/2014
Planning & Readiness Factors Order
Angela Fujan 01/23/2018
Summary of Employment Discussion Print
Data Entry
Angela Fujan 09/30/2010
VR Psychological Narrative Report Guidelines Print
Angela Fujan 08/31/2006
Audiology Calculating Tool - Excel Data Entry Angela Fujan
Functional Capacities Checklist Print
Order
Data Entry
Angela Fujan 08/17/2018
Impairments Checklist Print
Order
Angela Fujan
Nebraska VR ABI Screen Print
Data Entry
Keri Bennett Replaces the HELPS TBI Screening Tool and HELPS Follow-up Questionnaire.
Nebraska Brain Injury Information, Referral and Resource Facilitation Services Brochure Print
Order
Keri Bennett 03/01/2017 Print or order through Nancy Noha at ATP
Meet You Where You Are-Options Print
Janet Drudik 10/29/2015
Meet You Where You Are-Brochure Order
Janet Drudik 10/29/2015
Career Planning Preferences Print
Data Entry
Angela Fujan 01/01/2016
Nebraska Brain Injury Information, Referral and Resource Facilitation Services Brochure-Spanish Print
Order
Keri Bennett 09/11/2017 Spanish translation of the Nebraska Brain Injury Information, Referral and Resource Facilitation Services Brochure. Print or order through Nancy Noha at ATP
Order of Selection (OOS) Questions & Answers Print
Angela Fujan 05/08/2018
Information and Referral (I & R) to Other Programs Print
Paige Rose 06/05/2018 Used for CCIR appointments, and clients on the wait list during order of selection
Guide for Approval of Eligibility and Priority Groups Print
Angela Fujan 11/30/2017
Order of Selection Fact Sheet Print
Order
Angela Fujan 05/02/2018
Order of Selection Communication to VR staff on process for working with DDD while all categories are closed Print
Lindy Foley 06/04/2018
Order of Selection communication to VR staff on process for working with BH Regions while all categories are closed Print
Lindy Foley 06/04/2018
Q & A on Employment Plans Print
Carla Lasley 06/19/2018 Questions and answers are from a 6-19-18 Videoconference attended by VR staff.
Template, Background, & Instructions for Completion of Employment Plan (I/DD) Print
Data Entry
Carla Lasley
Template, Background, Instructions for BH Employment Plan Print
Carla Lasley 07/09/2018
Order of Selection Update for BH SE Milestones 7-3-18 Print
Carla Lasley 07/03/2018 this is an update to the OOS memo dated 6-14-18
Nebraska VR/DD Flow Chart Print
Paige Rose 10/01/2018
VR Referral form Print
Data Entry
Angela Fujan 08/01/2016 English and Spanish for all locations
Form Name Action Form Owner Revision Date Notes
Action Planner Order
Angela Fujan 08/31/2011
Appointment Reminder Postcard Order
Sandy Ham 05/20/2014
Assignment Purchases-Medicare Print
Cathy Callaway Must open this document in Excel
Assignment Purchases-Third Party Print
Cathy Callaway This document must be opened in Excel
Blank Memo Post Card Order
Sandy Ham
Case File Order List Print
Angela Fujan 10/29/2013
Check Medicaid Rates Print
Cathy Callaway Must open this document in Excel
Consumer Reimbursement Print
Cathy Callaway
Equipment Agreement Print
Data Entry
Angela Fujan 11/01/2013
High Cost Approval Print
Data Entry
Angela Fujan 10/31/2013
Next Steps Order
Angela Fujan 11/30/2010
Proof of Purchase Print
Data Entry
Cathy Callaway 06/02/2014
Suicide Call Print
Data Entry
Vicki Rasmussen 02/28/2009
Provider Invoice Print
Data Entry
Cathy Callaway 02/28/2013
Check 3rd Party Medicaid Rates Print
Cathy Callaway Use with Excel
Next Steps- Spanish Print
Angela Fujan 11/30/2015
Purchase of Goods and Services Print
Angela Fujan 05/01/2017
Form Name Action Form Owner Revision Date Notes
Corrective Action Plan Print
Data Entry
Cathy Callaway 02/28/2011
Discovery Booklet Print
Order
Angela Fujan 04/20/2018
IPE Amendment of Job Goal at Outcome/Termination of Service - English Print
Order
Data Entry
Angela Fujan 10/31/2013
IPE Amendment of Job Goal at Outcome/Termination of Service - Spanish Print
Data Entry
Angela Fujan 10/31/2013
IPE Community Services - English Print
Order
Data Entry
Angela Fujan 04/11/2017
IPE Community Services - Spanish Print
Data Entry
Angela Fujan 04/11/2017
IPE Job Goal & IPE Supported Employment - English Print
Order
Data Entry
Angela Fujan 04/11/2017
IPE Job Goal & IPE Supported Employment - Spanish Print
Data Entry
Angela Fujan 04/11/2017
IPE Services to QE2 Crosswalk Print
Angela Fujan 11/30/2014 Legal Size
IPE Supports - English Print
Order
Data Entry
Angela Fujan 01/30/2016
IPE Supports - Spanish Print
Data Entry
Angela Fujan 01/30/2017
IPE - Important Information for You - English Print
Order
Angela Fujan 07/31/2015 The IPE-Important Information for You is the renamed and revised version of the IPE Terms
IPE VR Provided Services - English Print
Order
Data Entry
Angela Fujan 03/14/2017
IPE VR Provided Services - Spanish Print
Data Entry
Angela Fujan 03/14/2017
Make Sure this Job is Right for You Print
Order
Data Entry
Angela Fujan 01/31/2014
IPE - Important Information You Need to Know When Writing Your Own IPE - English Print
Order
Angela Fujan 09/24/2014 This document is only given to clients when choosing to write their own IPE without the assistance of a VR Specialist
IPE - Important Information for You - Spanish Print
Order
Angela Fujan 05/24/2017 The IPE-Important Information for You is the renamed and revised version of the IPE Terms. This is the Spanish version of the information.
IPE - Important Information You Need to Know When Writing Your Own IPE - Spanish Print
Order
Angela Fujan 09/24/2014 This document is only given to clients when choosing to write their own IPE without the assistance of a VR Specialist, Spanish version.
Form Name Action Form Owner Revision Date Notes
15 Day Letter Print
Angela Fujan 06/02/2014
Office Director Letter Print
Angela Fujan 12/07/2017
Successful closure - no benefits Print
Angela Fujan 12/19/2016
Termination Letter Print
Angela Fujan 12/07/2017
OJE Letter - Unpaid 11-7-2018 Print
Paige Rose 11/07/2018
OJE Letter - State 11-7-2018 Print
Paige Rose 11/07/2018
OJT Letter - Nonpaid 11-7-2018 Print
Paige Rose 11/07/2018
OJT Letter - Private 11-7-2018 Print
Paige Rose 11/07/2018
OJT Letter - State 11-7-2018 Print
Paige Rose 11/07/2018
Welcome Letter with Link to Orientation Video-Constant Contact Sarah Chapin 12/13/2017
OJE/Job Shadow Letter - Background Check Print
Data Entry
Paige Rose 10/01/2018
Schedule A Certification Letter for VR Staff Print
Mary Matusiak 10/01/2018
Pre-Employment Transition Services Work Based Learning Letter-Paid Print
Data Entry
Brigid Griffin 08/30/2017
Pre-Employment Transition Services Work Based Learning Letter-Unpaid Print
Data Entry
Brigid Griffin 08/30/2017
Section 511: Employment Not Expected from Services Letter Paige Rose 09/05/2018
VR Eligibility for DD Letter Print
Data Entry
Paige Rose 11/20/2018
Pre-Employment Transition Services Non Participation letter Print
Brigid Griffin 04/11/2018
Pre-Employment Transition Services Welcome letter Print
Brigid Griffin 10/20/2017
Pre-Employment Transition Services Welcome Letter Spanish Print
Brigid Griffin 10/20/2017
Order of Selection Retention Letter Print
Angela Fujan 11/20/2017 Example of Retention letter sent out from State Office
Order of Selection Off Waiting List Letter Print
Angela Fujan 12/08/2017 Example of Off Wait List letter sent out by State Office
Pre-Employment Transition Services Eligibility/Priority Group Letter (New Students) Order of Selection Print
Brigid Griffin 07/11/2018 Example of Order of Selection Pre-Employment Transition Services Eligibility/Priority Group Letter (New Students) sent out by State Office
Pre-Employment Transition Services Eligibility/Priority Group Letter (New Students) Order of Selection Print
Brigid Griffin 07/11/2018 Example of Order of Selection Pre-Employment Transition Services Eligibility/Priority Group Letter (New Students) sent out by State Office
Orientation Welcome Letter-Word version Print
Sarah Chapin 12/14/2017
Successful closure - SS beneficiaries Print
Angela Fujan 12/19/2017
Successful closure - ID DD recipient Print
Angela Fujan 02/09/2018
CPAP Order of Selection letter 2&3 on the waiting list Print
Janet Drudik 03/07/2018
CPAP Order of Selection letter Priority group Print
Janet Drudik 03/07/2018
Order of Selection Adult Waiting List letter Angela Fujan 07/02/2018 Example of Adult waiting list letter sent out by State Office
Order of Selection Upgrading Priority Group Letter Print
Angela Fujan 08/31/2018
Form Name Action Form Owner Revision Date Notes
Direct Deposit Enrollment Print
Data Entry
Cinda Wacker 07/31/2013
Job Facts Guide Print
Order
Mary Matusiak 05/31/2014 Job Facts Guide is available as a fillable pdf.
Job Search Agreement - English Print
Order
Data Entry
Mary Matusiak 01/31/2013
Job Search Agreement - Spanish Print
Data Entry
Mary Matusiak 01/31/2013
Job Seeking Skills Training Application Print
Data Entry
Mary Matusiak
Job Seeking Skills Training Booklet - English Order
Mary Matusiak 12/01/2017
I-9 Checklist Print
Vicki Rasmussen
I-9 Form & Information Print
Vicki Rasmussen 10/01/2018
OJE/OJT Information Print
Data Entry
Cathy Callaway 12/04/2017
OJE/OJT Letter Checklist Print
Data Entry
Cathy Callaway
W4 Employee's Withholding Allowance Certificate Print
Vicki Rasmussen
Weekly Job Search Record Print
Order
Data Entry
Mary Matusiak
Work Opportunity Tax Credits - 9061 Individual Characteristics - English Print
Mary Matusiak
Work Opportunity Tax Credits - 9061 Individual Characteristics - Spanish Print
Mary Matusiak
Work Opportunity Tax Credits - 8850 - Pre-Screening Notice & Certification Request - English Print
Mary Matusiak
Work Opportunity Tax Credits - 8850 - Pre-Screening Notice & Certification Request - Spanish Print
Mary Matusiak
Work Opportunity Tax Credits - 8850 - Pre-Screening Notice & Certification Request Instructions Print
Mary Matusiak
On-the-Job Report Print
Data Entry
Paige Rose 11/27/2018 Replaces the OJT Training Progress Report and OJE Evaluation Report
Volunteer/Non-Paid Accident Coverage Vicki Rasmussen 07/01/2018 This form confirms that the State of Nebraska Vocational Rehabilitation has insurance in place for all registered volunteers and participants as outlined in the letter and signed by Pete Ricketts, Governor of the State of Nebraska.
Request for Certificate of Self-Insurance Print
Vicki Rasmussen 04/07/2015 Use URL to get form The form is a link to the DAS site so you have the current form
FOCUS Card Enrollment Form (Replaces AccelaPay) Print
Data Entry
Cathy Callaway 11/23/2015
Request Temporary Access Print
Vicki Rasmussen 04/25/2018
Community Work Assessment (CWA) Letter Checklist Data Entry Paige Rose 11/20/2018
Community Work Assessment (CWA) Consent Data Entry Paige Rose 11/26/2018
Community Work Assessment (CWA) Report Data Entry Paige Rose 11/27/2018
Bi-Weekly Schedule (2018) Information Print
Cathy Callaway 12/07/2017
OJT Private Invoice-2018 Print
Data Entry
Cathy Callaway 12/21/2017
OJE/OJT State Timesheet-2018 Print
Data Entry
Cathy Callaway 12/21/2017
Community Work Assessment (CWA) Time Log-2018 Print
Data Entry
Paige Rose 09/05/2018
Income under WIOA Print
Data Entry
Carla Lasley 04/13/2018
Time Conversion Chart Print
Cathy Callaway
Bi-Weekly Schedule (2019) Information Order
Cathy Callaway 12/13/2018
Form Name Action Form Owner Revision Date Notes
Budget Worksheet-Post-Secondary Print
Angela Fujan 05/31/2006
Budget Worksheet-Education Financial Aid Print
Angela Fujan 03/02/2016
Post Secondary Training Justification - PDF Print
Data Entry
Angela Fujan 09/30/2010
Student Financial Aid Report (SFAR-E) Print
Data Entry
Angela Fujan 04/30/2009
What You Should Know About VR Financial Aid Print
Angela Fujan 08/31/2010
Informational Interview Tool Print
Paige Rose 11/20/2018
Form Name Action Form Owner Revision Date Notes
NE VR Sign Language Interpreting Request Print
Order
Vicki Rasmussen 05/05/2016
VR Referral form Print
Data Entry
Angela Fujan 08/01/2016 English and Spanish for all locations
Release of Information English/Spanish Print
Order
Data Entry
Angela Fujan 05/21/2018
Request for Medical Information English/Spanish Print
Order
Data Entry
Angela Fujan 07/31/2017
BP/SSA 3288 Consent for Release of Information - Earnings Print
Data Entry
Carla Lasley 12/14/2018 Earnings (VR) English/Spanish
VR/SSA 3288 Consent for Release of Information - General Print
Data Entry
Carla Lasley 12/19/2007 English/Spanish
Waiver of Parent Signature Print
Brigid Griffin 07/09/2007
Self Employment Feasibility Referral Form Print
Data Entry
Julie Shively 08/16/2017 Revised Self-Employment referral form
Agrability Referral Print
Data Entry
Angela Fujan 03/31/2014
ATP/VR Referral Print
Data Entry
Nancy Noha 12/04/2017
Consent for Paid OJE/OJT Placement Order
Paige Rose 11/27/2018
Consent for Non-Paid Exploration Assessment or Training Placement Print
Order
Data Entry
Paige Rose 11/26/2018
BP/Benefits Orientation Checklist Print
Data Entry
Carla Lasley 02/01/2018
BP/DHHS Authorization for the Disclosure of Protected Health Information Print
Data Entry
Carla Lasley 06/28/2018
Authorization for Exchange of Information-Multi Agency Release Print
Carla Lasley 01/31/2018
BP/Benefits Services Referral Form Print
Data Entry
Carla Lasley 03/01/2018
VR/SSA 3288 Consent for Release of Information - Earnings Print
Order
Carla Lasley 11/30/2009
BP/SSA 3288 Consent for Release of Information - General Print
Order
Carla Lasley 12/14/2018
Maximus: Notification To Take Ticket Out of Assignment Print
Data Entry
Vicki Rasmussen 09/30/2012
Mediation Referral Print
Angela Fujan 03/31/2008
Service & Device Application Print
Nancy Noha 05/31/2014 Multi-Agency Form
Vocational Evaluation Referral Print
Paige Rose 10/02/2018
VR Criminal Background Request Print
Vicki Rasmussen 03/07/2018
DHHS Eligibility Release of Information (ROI) Print
Data Entry
Carla Lasley 12/14/2018
Title II: Social Security Disability Insurance Work Incentives Guide - 2018 Print
Carla Lasley 01/01/2018
Title XVI: Supplemental Security Income Work Incentives Guide - 2018 Carla Lasley 06/29/2018 Revised 1616b threshold amount
BP/Concurrent Work Incentive Guide 2018 Print
Carla Lasley 06/29/2018 Revised 1616b threshold amount-This form provides the adjusted calculation for those who receive both SSDI and SSI benefits.
Video & Media Information Release form Print
Data Entry
Sandy Ham 04/02/2018
Pre-Employment Transition Services Consent & Information Release Print
Data Entry
Brigid Griffin 03/11/2017
Pre-Employment Transition Services Consent & Information Release Spanish Print
Data Entry
Brigid Griffin 07/31/2017
Section 511: Refusal of Pre-Employment Transition Services (While still in High School) Data Entry Paige Rose 10/18/2018
Pre-Employment Transition Services Consent & Information Release Print
Data Entry
Brigid Griffin 03/11/2017
ATP-CPAP Facility Assessment Referral Form Print
Data Entry
Nancy Noha 07/18/2017 For BAM and CPAP staff use with businesses
Pre ETS Job Exploration Referral Data Entry Paige Rose 01/26/2018
Documentation of choice of Benefits Services providers Print
Carla Lasley 12/12/2018
BP/DHHS Authorization for the Disclosure of Protected Health Information-Spanish Print
Data Entry
Carla Lasley 06/28/2018
VR Referral form Print
Data Entry
Angela Fujan 08/01/2016 English and Spanish for all locations
Form Name Action Form Owner Revision Date Notes
Section 511: Refusal of Pre-Employment Transition Services (While still in High School) Data Entry Paige Rose 10/18/2018
Section 511: Refusal to Participate Data Entry Paige Rose 10/26/2018
Section 511: Documentation Checklist for Adults Data Entry Paige Rose 11/20/2018
Section 511: Documentation Checklist for Youth (under age 24) Print
Data Entry
Paige Rose 10/26/2018
Section 511: Discovery Payment Schedule Print
Paige Rose 11/27/2018
Information and Referral (I & R) to Other Programs Print
Paige Rose 06/05/2018 Used for CCIR appointments, and clients on the wait list during order of selection
Section 511: Information on Self-Advocacy, Peer Mentoring, and Self-Determination Opportunities Print
Paige Rose 10/26/2018 Used for CCIR appointments
Section 511 Decision Tree Print
Paige Rose 07/10/2018
Form Name Action Form Owner Revision Date Notes
Self Employment Discussion Questionnaire-Data Entry Print
Data Entry
Julie Shively 12/07/2017 Use this Word version to allow for expanding data entry. Tab between fields.
Self Employment Rates & Provider Print
Mary Matusiak 01/01/2018
Self Employment Personal Finance Worksheet Print
Data Entry
Julie Shively 02/07/2017
Self Employment-Advantages Print
Julie Shively 03/01/2017
Self Employment-GreenFlags/RedFlags Print
Julie Shively 06/09/2016
Self Employment Feasibility Referral Form Print
Data Entry
Julie Shively 08/16/2017 Revised Self-Employment referral form
Self Employment Process Chart Print
Julie Shively 01/26/2018
Supported Self-Employment Guidance Print
Mary Matusiak 05/23/2018
Form Name Action Form Owner Revision Date Notes
Supported Employment & Customized Employment-Intellectual Disabilities-Independent Provider Packet Print
Data Entry
Carla Lasley 10/31/2018
Supported Employment Milestone 1-Initiate Job Search Services I/DD Print
Data Entry
Carla Lasley 07/17/2017
Supported Employment Milestone 2-Employment Placement Report I/DD Print
Data Entry
Carla Lasley 07/17/2017
Supported Employment Milestone 3-Job Stabilization Report I/DD Print
Data Entry
Carla Lasley 07/17/2017
Supported Employment Milestone 5 Report - I/DD, ABI/Autism Supported & Customized Employment Print
Data Entry
Carla Lasley 03/02/2018
Payment Schedule Supported Employment Milestone ABI-ASD Print
Carla Lasley 04/14/2017
Payment Schedule Support Employment Milestone BH Print
Carla Lasley 04/14/2017
Supported Employment Milestone 4-VR Closure & SE Job Retention Plan I/DD Print
Data Entry
Carla Lasley 07/17/2017
VR Profile for Supported or Customized Employment Data Entry Paige Rose 10/26/2018
VR Profile for Supported or Customized Employment SAMPLE Data Entry Paige Rose 11/20/2018
Payment Schedule Customized Employment Milestone-I/DD Print
Paige Rose 11/27/2018
Payment Schedule Supported Employment Milestone -I/DD Print
Carla Lasley 05/30/2017
Supported Employment Milestone 30 Day Report I-DD Print
Data Entry
Carla Lasley 02/01/2018
Supported Employment Milestone 2-Customized-Employment Placement Report I/DD Print
Data Entry
Carla Lasley 07/17/2017
Section 511: Discovery Payment Schedule Print
Paige Rose 11/27/2018
Supported Employment Milestone 1 - Job Search Agreement BHABIA Print
Data Entry
Carla Lasley 05/01/2017
Supported Employment Milestone Alternative 1 - Job Retention Agreement BHABIA Print
Data Entry
Carla Lasley 05/01/2017
Supported Employment Milestone 2 - Job Placement Report BHABIA Print
Data Entry
Carla Lasley 05/01/2017
Supported Employment Milestone 3 - Job Stabilization Report BHABIA Print
Data Entry
Carla Lasley 05/01/2017
Supported Employment Milestone 4 - VR Closure & SE Job Retention Plan BHABIA Print
Data Entry
Carla Lasley 05/01/2017
Supported Employment Milestone 5 - Long Term Supports BHABIA Print
Data Entry
Carla Lasley 05/01/2017
Supported Employment Milestone 30 Day Report -I/DD Customized Print
Data Entry
Carla Lasley 03/01/2018
Supported Self-Employment Guidance Print
Mary Matusiak 05/23/2018
Nebraska VR/DD Flow Chart Print
Paige Rose 10/01/2018
ABI/Autism SE Supplemental Questionnaire Print
Data Entry
Carla Lasley 10/26/2018

Pre-Employment Transition Services

Form Name Action Form Owner Revision Date Notes
Pre-Employment Transition Services Consent for a Paid Work Based Learning Experience (14-15 y.o.) Print
Data Entry
Brigid Griffin 03/01/2017
Pre-Employment Transition Services Consent for a Paid Work Based Learning Experience (16+ y.o.) Print
Data Entry
Brigid Griffin 03/01/2017
Pre-Employment Transition Services Work Based Learning Experience Information Print
Data Entry
Brigid Griffin 12/04/2017
Pre-Employment Transition Services Work Based Learning Experience Report Print
Data Entry
Brigid Griffin 03/01/2017
Pre-Employment Transition Services Work Based Learning Experience Letter Checklist Print
Data Entry
Brigid Griffin 03/03/2017
Pre-Employment Transition Services Consent for a Non-paid Work Based Learning Experience Print
Data Entry
Brigid Griffin 12/03/2018
Pre-Employment Transition Services Consent for a Paid Work Based Learning Experience (14-15 y.o.) Spanish Print
Data Entry
Brigid Griffin 07/31/2017
Pre-Employment Transition Services Consent for a Paid Work Based Learning Experience (16+ y.o.) Spanish Print
Data Entry
Brigid Griffin 07/31/2017
Pre-Employment Transition Services Work Based Learning Experience Information Spanish Print
Data Entry
Brigid Griffin 12/04/2017
Pre-Employment Transition Services Consent & Information Release Spanish Print
Data Entry
Brigid Griffin 07/31/2017
Pre-Employment Transition Services Consent for Non-paid Work Based Learning Experience Spanish Print
Data Entry
Brigid Griffin 12/03/2018
Pre-Employment Transition Services Work Based Learning Experience Time Sheet-2018 Print
Data Entry
Brigid Griffin 12/21/2017
Income under WIOA Print
Data Entry
Carla Lasley 04/13/2018
Nebraska VR/SPED Inter-Departmental Agreement Print
Lindy Foley 08/22/2018 Inter-departmental agreement between Nebraska VR and the Office of Special Education (SPED)

Administrative

Form Name Action Form Owner Revision Date Notes
Vacation Carryover Request Print
Vicki Rasmussen
Volunteer/Unpaid Intern Print
Vicki Rasmussen This form is housed on Inside NDE.
Contracts, Letter Contracts, Purchasing Procedures Cathy Callaway
Direct Deposit Enrollment Print
Data Entry
Cinda Wacker 07/31/2013
Horizontal Wage Progression Vicki Rasmussen Contact NDE HR for this form.
Leave Advancement/LWOP Request Print
Vicki Rasmussen
I-9 Checklist Print
Vicki Rasmussen
I-9 Form & Information Print
Vicki Rasmussen 10/01/2018
Minority, Women, Disabled Owned Designation (MWD) Print
Cinda Wacker
Merit Stipend Request Vicki Rasmussen Contact NDE HR for this form
NDE Reference Check Vicki Rasmussen
Retirement Reception Cinda Wacker Contact NDE HR for this form
State Vehicle Waiver - NDE Print
Cinda Wacker
Work Schedule Change Request (will download to your Downloads folder) Print
Vicki Rasmussen
SOS Personnel Request form (Will download to your Downloads folder) Print
Data Entry
Vicki Rasmussen
FOCUS Card Enrollment Form (Replaces AccelaPay) Print
Data Entry
Cathy Callaway 11/23/2015
ADA Guidance Print
Vicki Rasmussen 02/24/2017
Bi-Weekly Schedule (2018) Information Print
Cathy Callaway 12/07/2017
Work Opportunity Tax Credits - 8850 - Pre-Screening Notice & Certification Request Instructions Print
Mary Matusiak
Bi-Weekly Schedule (2019) Information Order
Cathy Callaway 12/13/2018
Form Name Action Form Owner Revision Date Notes
DHHS Registry Check Print
Vicki Rasmussen 03/15/2018 VR Employees Only, Volunteers, Interns, Service Agreements
Case Review Instrument - Employment Process Print
Mary Matusiak
Case Review Instrument - Vocational Evaluation Print
Paige Rose 08/31/2018 Includes Case Review-Voc Eval instructions
Case Review-Supported Employment (Milestones) Print
Data Entry
Carla Lasley 06/21/2015
Case Review Instrument-Compliance Print
Angela Fujan
Confidentiality Agreement Print
Vicki Rasmussen 08/13/2018
Client Incident Report Print
Data Entry
Vicki Rasmussen
Direct Purchase Agreement (DPA) Print
Data Entry
Cathy Callaway
Employee Roster Information Print
Data Entry
Vicki Rasmussen 05/03/2017
Provider Program Review-Supported Employment Print
Data Entry
Carla Lasley
Case Review-Quality Case Review Instrument (Checklist) Print
Angela Fujan 03/02/2017
Service Agreement Data Entry Carla Lasley 11/15/2018
Team Connections Print
Data Entry
Vicki Rasmussen
Training Request Print
Data Entry
Vicki Rasmussen
TSB Log Print
Melysa Johnson
Video & Media Information Release form Print
Data Entry
Sandy Ham 04/02/2018
VR Community Connections Print
Data Entry
Vicki Rasmussen
Video Conference Participant List Print
Paige Rose 11/09/2018
VR Job Reference Questionnaire Print
Vicki Rasmussen
New Employee Benefits Begin Schedule Print
Vicki Rasmussen 01/11/2018
I-9 Checklist Print
Vicki Rasmussen
State Vehicle Waiver - VR Print
Vicki Rasmussen 06/30/2014 Includes an extra signature line for parent/guardian for transition students.
VR Vendor Office Listing Print
Cathy Callaway 12/31/2012
Fee Schedule Exception Guide Vicki Rasmussen 10/07/2015
Suicide Call Form Print
Data Entry
Vicki Rasmussen 12/16/2015
Code of Conduct Print
Data Entry
Angela Fujan 05/27/2016
Case Review - General Print
Data Entry
Angela Fujan 03/10/2017 referral to case closure
New Hire/Employee Roster Print
Vicki Rasmussen 10/03/2017
Case Review Instrument- Task Notes Print
Angela Fujan 04/20/2017
Summary of Case Review Findings Print
Data Entry
Angela Fujan 12/04/2017
Transition Partnership Planning Form Print
Data Entry
Brigid Griffin 05/01/2017 Stand alone Planning form from the Transition Services Planner - Guide for Educators
Case Review Instrument- Compliance Pre-Employment Transition Services Print
Data Entry
Brigid Griffin 04/02/2018
Training Plan Data Entry Vicki Rasmussen 09/19/2018
18/23 Month Assessment Action Plan Print
Data Entry
Vicki Rasmussen 09/05/2018
VR Criminal Background Request Print
Vicki Rasmussen 03/07/2018
Order of Selection (OOS) Talking Points Print
Data Entry
Lindy Foley 05/03/2018
Case Review Instrument- Clerical Associate Print
Data Entry
Vicki Rasmussen 07/18/2018
Nebraska VR/SPED Inter-Departmental Agreement Print
Lindy Foley 08/22/2018 Inter-departmental agreement between Nebraska VR and the Office of Special Education (SPED)
Bi-Weekly Schedule (2019) Information Order
Cathy Callaway 12/13/2018
Form Name Action Form Owner Revision Date Notes
Voter Registration Print
Vicki Rasmussen
Tax Exempt Form (Form 13) Print
Cathy Callaway 12/31/2016 Office Listing is included with the form
W4 Employee's Withholding Allowance Certificate Print
Vicki Rasmussen
W-9 & ACH Enrollment Print
Data Entry
Cinda Wacker
State Purchasing Bureau Non-CSI Justification Form Print
Data Entry
Cathy Callaway 04/24/2017
Bi-Weekly Schedule (2018) Information Print
Cathy Callaway 12/07/2017

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