Veterans’ Services Intake Form



Yüklə 11,91 Kb.
tarix21.06.2018
ölçüsü11,91 Kb.
#50887


Date:
Veterans’ Services Intake Form

Priority of service is the right of veterans and eligible military spouses to receive employment, training, and placement services before non-eligible persons, as long as other provisions of the law are met. Please complete this questionnaire to determine your eligibility for priority services provided by Disabled Veterans’ Outreach Program (DVOP) Specialists.



If you are not a Veteran, you do not need to complete this form.
Full Name: NCWorks Username:
Contact Information: ( ) Email: Home Phone  Cell Phone 
Complete this section if you are a veteran or an eligible military spouse.

An eligible veteran or eligible military spouse is determined to have a Significant Barrier to Employment (SBE) if he or she meets at least one of the six criteria below:

  1. *Are you a special disabled or disabled veteran who:

  • is entitled to compensation (or but for the receipt of military retired pay would be entitled to

compensation under laws administered by the Secretary of Veterans’ Affairs)?  Yes  No

  • was discharged or released from active duty because of a service-connected disability?  Yes  No

  1. Are you a homeless veteran?  Yes  No

  2. Are you a recently-separated service member who has been unemployed for 27 or more

weeks in the previous 12 months?  Yes  No

  1. Are you an offender who is currently incarcerated or who has been released from incarceration?  Yes  No

  2. Are you lacking a high school diploma or equivalent certificate?  Yes  No

  3. Are you a low-income individual?  Yes  No

  4. Are you an active duty service members being voluntarily or involuntarily separated through a

service reduction-in-force.  Yes  No

  1. A service members who receives a warm handover, or who produces a DD-2958 signed by their commander

documenting that they have not met Career Readiness Standards?  Yes  No

Are you the family caregiver of a wounded, ill, or injured service member?**  Yes  No

Complete this section if you are an eligible military spouse.

Are you the spouse of:

  1. A veteran who died of a service connected disability?  Yes  No

  2. A member of the Armed Forces who:

Is missing in Action?  Yes  No

Was captured in the line of duty?  Yes  No

Is being forcibly detained by a foreign government or power?  Yes  No

  1. A veteran who has a Department of Veterans Affairs total disability rating?  Yes  No

  2. A veteran who died while a Department of Veterans Affairs total disability rating existed?  Yes  No

Complete this section if you are a veteran age 18-24.

The Secretary of Labor has designated veterans ages 18-24 as a target population for veteran services. This group of veterans transitioning from active military service is expected to increase in the near future and may possess limited civilian work history and higher rates of unemployment.

  1. Are you between the ages of 18 and 24?  Yes  No

  2. Do you have limited civilian work history?  Yes  No

  3. Are you unemployed?  Yes  No

  4. Are you transitioning from active military service?  Yes  No

Military Documents

  1. Do you have a DD214 in your possession?  Yes  No


9/15

** Family Caregiver:

  • Caregiver who provides personal care services to the veteran.

  • Family member includes: (A) a parent, a spouse, a child, a step-family member, extended family member; (B) lives with, but is not a member of the family of the veteran.

* This form is used to determine your eligibility for additional services and is intended for use solely in connection with efforts to give priority of service to Eligible Veterans and Eligible Spouses that meet certain criteria. This information is being requested on a voluntary basis and will be kept confidential. Refusal to provide the information will not subject the applicant to any adverse treatment.
Do you need assistance in requesting military documents?  Yes  No

Yüklə 11,91 Kb.

Dostları ilə paylaş:




Verilənlər bazası müəlliflik hüququ ilə müdafiə olunur ©genderi.org 2024
rəhbərliyinə müraciət

    Ana səhifə