Attachment H _ Contract Referral.docx
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- Solicitation number
- 36C10D22R0001
- Issued by
-
Department of Veterans Affairs
About this file
This document is a contract referral form for vocational rehabilitation and employment services under Chapter 31 of Title 38. The form refers a veteran to a contractor for initial evaluation, case management, and employment services. Key details include the veteran's identifying information, disability rating, DOT code and job title, period of performance from to , and an obligation amount of $. The related federal contract opportunity is a solicitation for nationwide Chapter 31 vocational rehabilitation services. Responses are due by August 1, 2022. The solicitation seeks proposals for products and services to assist veterans, including initial assessments, case management, job readiness training, and follow-up support. The Department of Veterans Affairs is the contracting agency.
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Text version
Attachment H Revised
VR&E CONTRACT REFERRAL FORM
1. LAST - FIRST - MIDDLE NAME OF VETERAN
«FullName»
| 2a. Referral Number |
| 2b. TASK ORDER |
NUMBER
| 3. NAME OF CONTRACTOR |
| 4. CONTRACT NUMBER |
| 5. FISCAL YEAR |
| 6. ADDITIONAL IDENTIFYING DATA: | ||
| SSN: «SSN» (Last 4 Digits only) | DATE OF BIRTH: «DOB» | VETERAN’S ETD: «ETD» OIF/OEF |
ADDRESS: «MailingAddress»
| HOME PHONE: «HomePhone» | WORK PHONE: «WorkPhone» EMAIL ADDRESS: <<email>> |
| DISABILITY RATING: «CombDegree»% | Chapter: 31 PRIMARY DISABILITY DESCRIPTION: «DisabilitiesDesc» |
DOT CODE & DOT JOB TITLE: «RehabDOTCode» «RehabDOTTitle» SERIOUS EMPLOYMENT HANDICAP: Yes No PERIOD OF PERFORMANCE: DUE DATE:
7. SERVICES REQUIRED
| CLIN |
| BOC |
| TYPE OF SERVICE REQUIRED |
| Total Cost/ Flat Rate |
| «CaseMgr Name» |
| Authorized By |
Service Group A – Initial Evaluation (Ch 18 or 31)
| 2504 |
| Complete Initial Assessment |
| 2504 |
| Vocational Evaluation |
| 2504 |
| Transferable Skills Assessments |
| 2504 |
| Vocational Exploration |
| Service Group B – Case Management (Ch 18 or 31) |
| Cost Per Month |
| 2505 |
| Standard Case Management |
| 2505 |
| Intensive Case Management |
| 2505 |
| Follow-Up Case Management Services |
| Service Group C – Employment Services (Ch 18 or 31) |
| Cost Per Hour |
| 2506 |
| Job Readiness Assessment |
| 2506 |
| Job Readiness Development & Job Placement Services |
| 2506 |
| Follow-Up Services |
This allows you to provide this person with the services in Item 7. As shown in the contract, VA needs these services to process a claim for vocational rehabilitation, education and training, or for vocational and educational counseling. This individual must report for counseling for you to claim payment for providing these services. VA referrals are limited to the number of persons for which VA has obligated funds. At any time before you begin to deliver services to this counselee, VA may stop this authorization by written notice if payment would exceed the legal limits for contract counseling. VA cannot pay for services you begin to provide after you receive written notice.
| 8. ALLOTMENT ACCOUNT SYMBOL |
| 9. TITLE 38, U.S. CODE (Check applicable box) |
CH 31
10. OBLIGATION AMOUNT
11. DATE
«CurrentDate»
12. SIGNATURE AND TITLE OF REFERRING VRC
| Regional Office | |
| Submit Report to: | |
| Period of Performance: | to |
File details come from the government source that posted it. Updated .