Exhibit_B_-_Pre-Employment_Transition_Services_Request_for_Students_with_Disabilities.pdf

RSA-1305AFORFF (1-21) ARIZONA DEPARTMENT OF ECONOMIC SECURITY

Rehabilitation Services Administration

Pre-employment Transition Services Request Form for Students with Disabilities

Initial request for services Continuation of services

I am currently a VR Client VR Counselor Name (if applicable):

STUDENT NAME:

(First) (Middle) (Last)

MAILING ADDRESS: (No., Street)

CITY:

SCHOOL NAME:

SCHOOL PHONE NUMBER:

If you will need accommodations to participate in services, please describe what you will need here:

Pre-Employment Transition Services Requested: (Check all that apply)

Job Exploration Counseling Work Based Learning Experience Workplace Readiness Training

Self-Advocacy Instruction/Peer Mentoring Counseling on opportunities for post-secondary education/training

Requesting the above services to be provided by this Contractor (Company Name):

Complete below information for initial request:

GENDER: Date of Birth:

(if available)

Race/Ethnicity (check all that apply):

Asian American Indian/Alaska Native - Tribal Affiliation:

Black/African American Hispanic/Latino Native Hawaiian/Pacific Islander White

Are you receiving services from any of the following (select all that apply):

Department of Child Safety Behavioral Health Division of Developmental Disabilities

By signing this form, I am requesting Pre-employment Transition Services from the Arizona Rehabilitation Administration/Vocational Rehabilitation (VR) program. I understand that in order to pursue VR services, other than Pre-employment Transition Services, I will need to complete an application and provide VR with information needed to determine my eligibility. For the specific purpose of participation in Pre-Employment Transition Services , I grant permission for my school to release information to VR, and for VR to use personal and demographic information identified in this form to track the services were provided to me. The confidentiality of personal information requested on this form and with this authorization is protected by 34 CFR 361.38.

STUDENT NAME (Please Print):

STUDENT SIGNATURE:

(If participant is under 18, a parent or legal guardian signature is required. Legal guardianship documents must be provided)

PARENT LEGAL GUARDIAN NAME:

(Printed)

(Signature)

Equal Opportunity Employer / Program • Auxiliary aids and services are available upon request to individuals with disabilities

• To request this document in alternative format or for further information about this policy, contact your local RSA office;

TTY/TDD Services: 7-1-1 • Disponible en español en línea o en la oficina local.

RSA-1305AFORFF (1-21) PAGE 2

Pre-employment Transition Services Request Form for Students with Disabilities

STUDENT WITH A DISABILITY VERIFICATION

Definition: A ‘student with a disability’ means an individual with a disability in a secondary, postsecondary, or other recognized education program who is not younger than 14 and not older than 22 years of age; is eligible for, and receiving special education or related services under Part B of IDEA; or who is a student with a disability under section 504. This includes secondary students who are homeschooled, and students in non-traditional secondary education programs such as special education programs within the juvenile justice system, GED programs, and occupational training programs.

If this request form is being completed by school personnel, please verify the following:

By signing this form, I verify that the individual identified above meets the definition of a student with a disability and is

A student with a disability for the purposes of section 504; or

A student with a disability and is receiving transition services under an Individualized Education Plan (IEP)

School Personnel Name:

(Printed)

(Signature)

If this request form is being completed by VR personnel, please verify the following:

By signing this form, I verify that the individual identified above meets the definition of a student with a disability and is:

A student with disability for the purposes of Section 504; or

Eligible or potentially eligible for VR services

VR Personnel Name:

(Printed)

(Signature)

If this request form is being completed by non-school/VR personnel, one of the following supporting documents must be included with the submitted request form:

Individualized Education Plan (IEP) or 504 Plan Proof of receipt of SSI/SSDI based on individual’s own disability (SSI/SSDI award letter) Medical or psychological documentation with diagnosis signed by a licensed professional

Contractor Use Only

CONTRACTOR NAME:

Services Requested (Check all that apply and provide total number of sessions and dates to complete workshop category type):

Job Exploration Counseling No. Sessions/Dates

Work-Based Learning Experience(s) No. Sessions/Dates

Workplace Readiness Training No. Sessions/Dates

Self-Advocacy Instruction/Peer Mentoring No. Sessions/Dates

Counseling on Opportunities for Enrollment in Comprehensive Transition/Post-Secondary Education Program

No. Sessions/Dates

The student/family has been provided information on how to pursue Vocational Rehabilitation services

Comments:

Signature of Contractor Representative

Please submit this completed form and supporting documentation (if applicable) to:

RSATransition@azdes.gov