Case No. When completing the form, remember comments are optional. District: Case Review Form Month/Year Meets Criteria Random Reviewer Counselor Caseload No. Status Applicant Date Eligibility Date Primary Impairment (optional) Impairment Code Priority Category IPE Date Closure Date REFERRAL/APPLICATION Questions Comments Yes No N/A 1. Was the application completed and trial with all ---- required signatures? 2. If the case was determined to be ineligible, was it implemented per agency guidelines? Further Comments: IF THIS CASE IS INELIGIBLE, PLEASE STOP REVIEW. ELIGIBILITY Questions Comments Yes No N/A 1. Is there documentation to support the following four eligibility questions? ------------------ ***If you answer to a-d, please explain. “NO” a) Does the applicant have a physical or mental ---- impairment? b) Does the individual have functional limitations which (in conjunction with attendant factors) result ---- in a substantial impediment to employment? c) Are VR services REQUIRED to prepare for, ---- secure, retain, or regain employment? d) There is a presumption that the applicant can benefit in terms of employment outcome. (N/A should only be marked if currently in Trial Work Experience). 2. Does the case record assess and sufficiently document the individual’s physical and/or mental ---- impairments? 3. Were all the functional limitations assessed and ---- identified appropriately? 4. Was the following question answered appropriately on the Eligibility Worksheet: how the functional “Explain ---- limitations and attendant factors impede employment for this individual”? Questions Comments Yes No N/A
Case No. When completing the form, remember comments are optional. Case Review Form District: Month/Year Meets Criteria Random Reviewer Counselor Caseload No. Status Applicant Date Eligibility Date Primary Impairment (optional) Impairment Code Priority Category IPE Date Closure Date REFERRAL/APPLICATION Yes No N/A Questions Comments ---- 1. Was the application completed and with all required signatures? 2. If the case was determined to be ineligible, was it implemented per agency guidelines? Further Comments: IF THIS CASE IS INELIGIBLE, PLEASE STOP REVIEW. ELIGIBILITY Yes No N/A Questions Comments ------------------ 1. Is there documentation to support the following four eligibility questions? ***If you answer “NO” to a-d, please explain. ---- a) Does the applicant have a physical or mental impairment? ---- b) Does the individual have functional limitations which (in conjunction with attendant factors) result in a substantial impediment to employment? ---- c) Are VR services REQUIRED to prepare for, secure, retain, or regain employment? d) There is a presumption that the applicant can benefit in terms of employment outcome. (N/A should only be marked if currently in Trial Work Experience). ---- 2. Does the case record assess and sufficiently document the individual’s physical and/or mental impairments? ---- 3. Were all the functional limitations assessed and identified appropriately? ---- 4. Was the following question answered appropriately on the Eligibility Worksheet: “Explain how the functional limitations and attendant factors impede employment for this individual”? Yes No N/A Questions Comments trial