13-Attachment 05-VR2897 Orientation and Mobility Referral.pdf
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- Solicitation number
- 3202600155
- Issued by
- Texas
About this file
This is an Orientation and Mobility (O&M) Referral Form used by the Texas Workforce Commission Vocational Rehabilitation (TWC-VR) Services division to refer customers for O&M services. The form is designed to be completed by VR Counselors or Independent Living Services for Older Individuals who are Blind (ILS-OIB) workers and captures essential customer information including name, date of birth, address, contact information, and primary language. The referral identifies specific O&M goals that may apply to the customer, such as guided techniques, orientation to home or community, cane skills, dog guide training, and travel skills for both familiar and unfamiliar areas. The form also documents circumstances that may impact service delivery, including visual diagnosis, secondary disabilities, communication methods for deaf-blind customers, educational level, health issues, safety concerns, visual acuity measurements, and visual field information.
This referral form is part of a broader Open Enrollment contract opportunity through TWC-VR to provide Orientation and Mobility Services to VR customers throughout Texas. The services are available to qualified O&M providers serving TWC-VR Workforce Solutions offices statewide. The form serves as the intake document linking customers identified as needing O&M services with available providers, enabling systematic referral and service coordination across the state's vocational rehabilitation program.
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Text version
VR2897 (10/17) O&M Referral Page 1 of 2
Texas Workforce Commission
Vocational Rehabilitation Services
Orientation and Mobility (O&M) Referral
Customer Information (required)
VR Counselor or Independent Living Services for Older Individuals who are Blind (ILS-OIB) worker name:
Caseload Number:
Office Number:
O&M Provider:
Date of Referral:
Customer Name:
DOB:
Primary Language:
Customer Address:
City:
State:
ZIP Code:
Telephone Number:
Alternate Contact:
Best Day(s) to Contact (if known):
Customer’s and/or VR Counselor or IL/OIB worker travel concerns:
Reason for Request (required)
O&M Goal(s) of the Customer: check box(s) below that may apply
Guided technique(s)
Evaluation purposes only
Orientation to home
Orientation to surrounding community
Basic indoor cane skills
Residential travel
Semi-business travel
Negotiate stairs
Orientation Skills with dog guide
Use of Para transit
Business travel
Dog guide information
Travel in familiar areas
Travel to unfamiliar areas
Unsure if O&M Skills are needed
Other O&M goals (please describe)
Circumstances that May Impact Services (required)
Visual Diagnosis:
Secondary Disability:
If secondary disability is deaf blindness, what is the customer’s primary form of communication?
SAMPLE
VR2897 (10/17) O&M Referral Page 1 of 2
Helpful Information (complete if known)
Level of Education:
Known Health Issues/ Safety Concerns:
Visual Acuity:
OD:
OS:
Visual Fields:
Additional Information:
SAMPLE
File details come from the government source that posted it. Updated .