Page 5 - Application for Services
P. 5
SERVICES AND PROGRAMS
APPLICATION FOR SERVICES
Paper version for field intakes
EMPLOYMENT: PAST EMPLOYMENT
Employer name: Job title:
City: State: Approx. start date:
Length of emp.: Full-time Part-time Wage: $ per
Employer name: Job title:
City: State: Approx. start date:
Length of emp.: Full-time Part-time Wage: $ per
Employer name: Job title:
City: State: Approx. start date:
Length of emp.: Full-time Part-time Wage: $ per
EMPLOYMENT: EMPLOYMENT LOGISTICS & BARRIERS
Modes of transportation:
Valid driver’s license Requires specialized transportation support
Eligible to work in US Lacks basic literacy skills
Unable to communicate in English Unable to sustain a full day’s work
Needs to arrange childcare No US work history
No work history in past six months History of short-term employment
SERVICE HISTORY: GENERAL
Participant has received services from VRS in past
Where:
Participant has received services through VA in past
Name of doctor: From when: to when:
Participant has had a worker’s compensation claim in past
Describe:
Note to staff completing intake: You MUST enter the data from this form into the electronic Application for
Services; do not submit this form to the Excellence Team for data entry.
The electronic Application for Services can be found via the Insider → Services and Programs menu →
Forms.
GESMN-Internal Use Only | Revised 10/23/2019 Page 5
