[nfbmi-talk] Fw: [System7] V R Application Signature Form - Harcz, Paul (XXX-XX-3817)

joe harcz Comcast joeharcz at comcast.net
Wed Oct 30 20:39:38 UTC 2013


V R Application Signature Form - Harcz, Paul (XXX-XX-3817)
----- Original Message ----- 
From: Wilson, Debbie (LARA) 
To: joeharcz at comcast.net 
Sent: Wednesday, October 30, 2013 4:17 PM
Subject: FW: [System7] V R Application Signature Form - Harcz, Paul (XXX-XX-3817)


Hi Joe

Please sign the VR application for services and return it to BSBP. Leamon said that he has spoken with you by phone and you stated that your family home is on a farm. You also stated that you perform work on the farm as your family has fruit trees. You are also an attendant providing assistance to your parents who are ill at this time. Please provide a written statement of the services that you are requesting and how they will assist you in being able to reach the vocational goal of unpaid family worker as I want to make sure that I am doing everything possible to assist you. Thanks

 

From: wilsond9 at michigan.gov [mailto:wilsond9 at michigan.gov] 
Sent: Wednesday, October 30, 2013 3:57 PM
To: Wilson, Debbie (LARA)
Subject: [System7] V R Application Signature Form - Harcz, Paul (XXX-XX-3817)

 

      Department of Licensing And Regulatory Affairs 
     
      Consumer Services Division 
     
      BUREAU OF SERVICES FOR BLIND PERSONS (BSBP)
     

 

 

 

V R Application Signature Form

 

      Current Name:
      

 

      Title: 
     Mr.
     

      Last Name:
     Harcz
     

 

      First Name: 
     Paul
     Middle Initial:
     J
     
      Suffix: 
      
      Salutation: 
      

      Use this Name?
     X
     

 

       
     

      Social Security: 
     XXX-XX-3817
     Date of Birth: 
     12/13/1952
     
      Gender: 
     M
       

 

      APPLICATION FOR VOCATIONAL REHABILITATION SERVICES 
     
      In accordance with the 1998 Amendments to the Rehabilitation Act of 1973 and Public Act 260 of the State of Michigan, I am applying for vocational rehabilitation services. 
     

 


      ELIGIBILITY
     
      I understand that in order to be eligible I must have a visual impairment  as defined by the Michigan Bureau of Services for Blind Persons (B S B P), the impairment must constitute or result in a significant impediment to employment and I must need vocational rehabilitation services in order to prepare for employment. It is presumed that I can benefit in terms of an employment outcome as a result of vocational rehabilitation services unless the B S B P can demonstrate by clear and convincing evidence that I am not capable of an employment outcome. This determination of eligibility will, to the extent possible, be based on existing information and will be completed within 60 days, unless my counselor and I mutually agree that an extension is necessary due to exceptional and unforeseen circumstances beyond my control or the agency's control and I sign an agreement that an extension of time is warranted.   The extension must be for a specific period of time. 

       

      If I am eligible, an Individual Plan for Employment (I P E) will be written with my direct participation.  In the development of this plan I will be given comprehensive information in order to assist me in making appropriate choices of service with my counselor.  My Counselor and I will review this plan every 12 months to assess my progress towards my Employment Objective.  I will be included in any decisions to change this plan.  I will receive copies of information pertinent to my case in the media I have indicated, e.g. Braille, tape, large print, computer disk, or regular print. 
     

 


      ORDER OF SELECTION
     
      Under an order of selection, I will be classified based on the categories below.  In the most severe category I may be eligible for all appropriate paid and non-paid services.  In lower categories I may only be eligible for non-paid services which might include diagnostic service, counseling and guidance, referral and job placement.  If I am found eligible for services I will be assigned to the highest possible category.  My category may change should my circumstances change. 
     

 


      SELECTION CATEGORIES
     
      1.  Individuals with the most significant disabilities;

      2.  Individuals with significant disabilities;

      3.  Individuals with less significant disabilities;

      4.  Individuals with non-significant disabilities;
     

 


      INELIGIBILITY
     
      If my impairment is judged to be too severe to allow me to benefit from services at any time in the vocational rehabilitation process, I must be allowed to undergo an extended assessment, which may last up to 18 months before I may be determined ineligible.  The basis for an ineligibility decision will be recorded in my record and will be certified by an appropriate staff person. 
     

 


      CONFLICT RESOLUTION AND RIGHTS
     
      Most conflicts arise out of miscommunication. The following steps are to assist in the resolution of the conflict: 

      1.  Administrative Review - A meeting between you and your counselor/teacher, his/her supervisor and an agency administrator for the purpose of resolving the conflict. 

      2.  Mediation Services - A meeting between you and your counselor/teacher and his/her supervisor conducted by an impartial professional mediator. 

      3.  Fair Hearing - A hearing before an Administrative Law Judge designed to settle conflicts. The Administrative Law Judge will render a ruling regarding your issues. If you are not satisfied with the decision of the Administrative Law Judge you may appeal this decision to the Director of the Department of Labor and Economic Growth. 

      4.  At no time will the above three forms of conflict resolution be used to delay the scheduling of a Fair Hearing, if you choose. 

      To request an Administrative Review contact the supervisor in the region at 1-800-292-4200. To arrange for Mediation Services or a Fair Hearing you may contact the Michigan Bureau of Services for Blind Persons Hearing Coordinator at 1-800-292-4200 or by making the request by phone or in writing to your Counselor/Teacher or the Hearing Coordinator. There is no cost to you for these activities. However, the agency will not pay the costs, if any, for an advocate or attorney. 

       

      You have the right to be represented by an advocate of your choosing at any time during the rehabilitation process or the conflict resolution activities mentioned above. You also have the right to obtain assistance through the Client Assistance Program (CAP) at any time. CAP may be reached at 1-800-288-5923. 


      ALL SERVICES WILL BE AVAILABLE TO ME REGARDLESS OF RACE, SEX, RELIGION, AGE, NATIONAL ORIGIN, COLOR, MARITAL STATUS, IMPAIRMENT OR POLITICAL BELIEF. 


      The above information has been discussed with me and I have received a copy in the media of my choice. 


     

 

                  Paul Harcz 
                  
           
            Client
           
      
      
            Date 
           
     

 

 



More information about the NFBMI-Talk mailing list