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Vocational Rehabilitation Service Forms

Questions about VR forms can be emailed to vrsm.support@twc.texas.gov.

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Form   Form Title Word Excel PDF Instr Revised  
VR1020 TWC Substitute W-9 and Direct Deposit Form     PDF TWC Substitute W-9 and Direct Deposit Form, VR1020INST - Instruction Sheet 06/27/2018
VR1020-S Forma W-9 Sustituta y de Depósito Directo del TWC     PDF Forma W-9 sustituta y de depósito directo del TWC, VR1020INST-S - Instruction Sheet 09/01/2016
VR1021 Consumer or Parent Information and Direct Deposit     PDF   08/01/2022
VR1021-S Información del Cliente o de los Padres/Guardas y de Depósito Directo     PDF Información del cliente o de los padres/guardas y de depósito directo, VR1021INST-S - Instruction Sheet 09/01/2016
VR1050 Ticket to Work Partnership Plus—Employment Advancement Payment MS Word     MS Word 10/01/2017
VR1200 Provider Feedback MS Word     MS Word 09/01/2022
VR1211 Provider Application MS Word       10/01/2017
VR1305 Child Support Certification MS Word     MS Word 11/01/2017
VR1309 Contractor Notice of Appeal Rights MS Word     MS Word 07/01/2021
VR1487 Designation of Applicant or Customer Representative MS Word       10/01/2017
VR1487-S Designación del Representante del Solicitante o Cliente MS Word       10/01/2017
VR1505 Request for Due-Process Hearing and/or Mediation MS Word   PDF Sig   06/01/2021
VR1505-S Solicitud para audiencia de proceso debido y/o mediación MS Word   PDF Sig   06/01/2021
VR1512 Benefits and Work Incentives Planning Referral MS Word       02/01/2023
VR1600 Work Experience Services Referral MS Word       06/01/2022
VR1601 Work Experience Plan and Placement Report MS Word       02/01/2023
VR1604 Work Experience Training Report MS Word       02/01/2023
VR1609 On-the-Job Training Worksheet MS Word       10/13/2021
VR1628 Attendant Care Reimbursement—Request for Rate Exception     PDF   07/01/2015
VR1629 Referral for Career Planning Assessment MS Word       02/01/2023
VR1630 Career Planning Assessment MS Word       02/01/2023
VR1631 Referral for Supported Employment Services MS Word       02/01/2023
VR1632 Supported Employment Plan and Employment Report MS Word       02/01/2023
VR1633 Supported Employment Job Development and Job Analysis Report MS Word       02/01/2022
VR1634 Supported Employment Training Plan and Job Retention Report MS Word       02/01/2023
VR1640 Referral for Supported Employment Services MS Word       06/03/2019
VR1641 Supported Employment Assessment Report (SEA) MS Word       07/01/2021
VR1642 Supported Employment Services Plan 1 MS Word       09/01/2020
VR1643 Supported Employment Services Plan 2 - Placement, Job Analysis, and Training Plan MS Word       07/01/2021
VR1644 Supported Employment Services Time Tracking Log MS Word       09/01/2020
VR1645 Supported Employment Training and Progress Report MS Word       07/01/2021
VR1646 Supported Employment Job Stability Justification Summary MS Word       07/01/2021
VR1647 Supported Employment Services Closure Summary MS Word       07/01/2021
VR1800 Self-Employment Referral MS Word       11/01/2022
VR1801 Customer Profile and Self-Employment Exploration MS Word       02/01/2023
VR1802 Concept Development and Feasibility Study MS Word       02/01/2023
VR1803 Self-Employment Simple Business Plan MS Word       10/01/2017
VR1804 Self-Employment Comprehensive Business Plan MS Word       10/01/2017
VR1805-1 Self-Employment Financial Projections Spreadsheet (Statutory Blindness)   MS Excel     12/01/2022
VR1805-2 Self-Employment Financial Projections Spreadsheet   MS Excel     12/01/2022
VR1806 Self-Employment Financial Actual Spreadsheet   MS Excel     10/01/2017
VR1808 Supported Self-Employment Assessment (SSEA) MS Word       06/01/2022
VR1809 Supported Self-Employment Concept Development MS Word       02/01/2023
VR1810 Supported Self-Employment Feasibility Study MS Word       10/01/2017
VR1811 Supported Self-Employment Services Plan (SSESP) and Benchmark Report MS Word       02/01/2023
VR1812 Supported Self-Employment Business Plan Support Summary Report MS Word       02/01/2023
VR1813 Supported Self-Employment Business Plan MS Word       10/01/2017
VR1814 Supported Self-Employment Support Summary (SSE-SS) MS Word       02/01/2023
VR1815 Certified Business Technical Assistance Consultant (CBTAC) Support Summary Report MS Word       02/01/2023
VR1820 Request to Receive Pre-Employment Transition Services MS Word       12/01/2021
VR1820-S Solicitud para recibir servicios de transición previos al empleo MS Word       12/01/2021
VR1823 Pre-Employment Transition Services (Pre-ETS) Progress Report MS Word       02/01/2023
VR1824 Referral for Contracted Pre-Employment Transition Services (Pre-ETS) Services MS Word       02/01/2023
VR1825 Pre-ETS Curriculum Checklist MS Word       01/15/2021
VR1836 Vocational Evaluation Referral MS Word       07/01/2021
VR1837 Report for Vocational Evaluation MS Word       02/01/2023
VR1838 Situational Assessment and Work Sample Report MS Word       02/01/2023
VR1840 Job Placement Services - Referral MS Word       02/01/2023
VR1841 Non-Bundled Job Placement Services Data Sheet, Application, and Résumé Training MS Word       02/01/2023
VR1842 Non-Bundled Job Placement Services Interview Training Report MS Word       02/01/2023
VR1845A Bundled Job Placement Services Placement Plan Part A MS Word       02/01/2023
VR1845B Bundled Job Placement Services Plan Part B and Status Report MS Word       02/01/2023
VR1846 Bundled Job Placement Services Benchmark A Training Report MS Word       02/01/2023
VR1850 Employment Data Sheet MS Word       05/03/2021
VR1877A Environmental Work Assessment Report Part A MS Word     MS Word 10/01/2017
VR1877B Environmental Work Assessment Report Part B   MS Excel     11/01/2017
VR1877C Environment Work Assessment Signature Page Part C MS Word       10/01/2020
VR1878 Environmental Work Assessment Time Log MS Word       10/01/2017
VR1879 Referral Form for Services for Neurodevelopmental Disorders MS Word       07/01/2021
VR1880 Autism Spectrum Disorder Supports Plan MS Word       11/01/2018
VR1881 Autism Spectrum Disorder Supports Time Log and Progress Report MS Word   PDF   10/01/2021
VR1882 Autism Service Premium Report MS Word       02/01/2023
VR1883 Blind Premium Report MS Word       11/01/2022
VR1884 Assistive Technology Services for Sight-Related Disabilities Referral MS Word       06/01/2022
VR1886 Assistive Technology Evaluation MS Word       02/01/2023
VR1888 Assistive Technology Training Results MS Word       02/01/2023
VR1990 Paid Work Experience Worksite Agreement MS Word       08/02/2021
VR1990-S Experiencia Laboral Remunerada Acuerdo sobre el lugar de trabajo MS Word       05/02/2022
VR1991 Referral for Embedded Pre-Employment Transition Services (Pre-ETS) MS Word       09/01/2021
VR1992 Embedded Pre-Employment Transition Services (Pre-ETS) Progress Report MS Word       02/01/2023
VR2006E Interagency Eye Examination Report MS Word       10/01/2017
VR2180 Maintenance Expense Log MS Word   PDF Sig   05/03/2021
VR2180-S Registro de gastos de mantenimiento MS Word   PDF Sig   05/03/2021
VR2181 Transportation Log MS Word   PDF Sig   05/03/2021
VR2181-S Registro de transporte MS Word   PDF Sig   05/03/2021
VR2305 Certificate of Medical Necessity Physician Order for Blood Pressure Monitor MS Word       09/03/2019
VR2868 Assistive Technology Training Report MS Word       02/01/2023
VR2883 Diabetes Self-Management Education Referral Form MS Word       10/01/2017
VR2884 Diabetes Self-Management Educator Notes MS Word       02/01/2023
VR2888 Diabetes Self-Management Education Assessment MS Word       02/01/2023
VR2889 Diabetes Self-Management Education Services - Adaptive Diabetes Equipment Receipt MS Word       06/03/2019
VR2891 ILS-OIB Customer Services Progress Report MS Word       02/01/2023
VR2894 Orientation and Mobility Assessment MS Word       02/01/2023
VR2896 Orientation and Mobility Training MS Word       02/01/2023
VR2897 Orientation and Mobility Referral MS Word       10/01/2017
VR2900 Diabetes Self-Management Education Post Training Assessment MS Word       02/01/2023
VR2901 Diabetes Self-Management Education Pre- and Post-Assessment MS Word       02/01/2023
VR2902 Assistive Technology Training Baseline Assessments MS Word       06/01/2022
VR2922 Orientation and Mobility Weekly Internship Observation MS Word       10/01/2017
VR2923 Orientation and Mobility Internship Performance Evaluation MS Word       10/01/2017
VR2954 Comprehensive Assessment for ILS-OIB Program MS Word       02/01/2023
VR3100 General Physical Examination Report MS Word       10/01/2017
VR3101 Consultant Review MS Word   PDF Sig   06/01/2021
VR3102 Pulmonary Evaluation Report MS Word   PDF   11/01/2017
VR3103 Cardiac Evaluation Report MS Word   PDF MS Word 11/01/2017
VR3104 Acknowledgement for Noncertified Interpreter MS Word   PDF Sig   04/01/2022
VR3105A Hearing Evaluation Report: Customer Questionnaire MS Word       10/01/2017
VR3105A-S Informe de evaluación de la audición: Cuestionario para el cliente MS Word       10/01/2017
VR3105B Hearing Evaluation Report: Otological Examination MS Word   PDF Sig   06/01/2022
VR3105C Hearing Evaluation Report: Audiometric Examination MS Word   PDF Sig   10/01/2017
VR3105D Hearing Evaluation Report: Hearing Aid Recommendations MS Word   PDF Sig   03/01/2023
VR3105E Hearing Aid Fitting and Post-Fitting Report MS Word       01/15/2021
VR3105F Hearing Aid and Hearing Aid Accessories Return MS Word       06/01/2022
VR3106 Work Restriction Checklist MS Word     MS Word 11/01/2017
VR3108 Dental Report MS Word   PDF MS Word 11/01/2017
VR3109 Eye Surgery and Treatment Recommendations MS Word       12/01/2020
VR3110 Surgery and Treatment Recommendations MS Word   PDF Sig   08/27/2018
VR3111 End-Stage Renal Disease Evaluation MS Word   PDF MS Word 11/01/2017
VR3112 Cancer/Diabetes Disability Medical Report MS Word       08/01/2022
VR3118 Hospital Facility Information MS Word       06/01/2021
VR3121 Referral for Work Readiness Services MS Word       02/01/2023
VR3122 Vocational Adjustment Training (VAT): Explore the "You" in Work MS Word       02/01/2023
VR3123 Vocational Adjustment Training (VAT): Soft Skills for Work Success MS Word       02/01/2023
VR3124 Vocational Adjustment Training (VAT): Soft Skills to Pay the Bills MS Word       02/01/2023
VR3125 Vocational Adjustment Training (VAT): Entering the World of Work MS Word       02/01/2023
VR3126 Vocational Adjustment Training (VAT): Job Search Training MS Word       02/01/2023
VR3132 Vocational Adjustment Training (VAT): Disability Disclosure Training MS Word       02/01/2023
VR3133 Vocational Adjustment Training (VAT): Money Smart MS Word       02/01/2023
VR3134 Vocational Adjustment Training (VAT): Public Transportation Training MS Word       02/01/2023
VR3135A Vocational Adjustment Training Specialized Evaluation MS Word       02/01/2023
VR3135B Vocational Training Specialized Training Plan MS Word       02/01/2023
VR3136 Vocational Adjustment Training Specialized Progress Report MS Word       02/01/2023
VR3137A Personal Social Adjustment Training and Work Adjustment Training Evaluation MS Word       02/01/2023
VR3137B Personal Social Adjustment and Work Adjustment Training Plan MS Word       02/01/2023
VR3138 Personal Social Adjustment Training and Work Adjustment Training Report MS Word       02/01/2023
VR3139 Vocational Adjustment Training (VAT): Exploring Postsecondary Education and Training MS Word       02/01/2023
VR3141 Referral for Wage Services - WorkQuest MS Word       11/01/2021
VR3142 Worksite Agreement for Wage Services - WorkQuest MS Word       11/01/2021
VR3314 Job Skills Training Referral MS Word       02/01/2023
VR3315 Job Skills Training Progress Report MS Word       02/01/2023
VR3316 On-the-Job Training Progress Report MS Word       07/01/2021
VR3321 Proprietary School Training Information MS Word       11/01/2017
VR3360 Referral for Project SEARCH MS Word       04/01/2022
VR3361 Project SEARCH Asset Discovery Report MS Word       02/01/2023
VR3362 Project SEARCH Progress Report MS Word       02/01/2023
VR3363 Project SEARCH Job Placement Services Plan MS Word       02/01/2023
VR3364 Project SEARCH Placement Report MS Word       02/01/2023
VR3380 Referral for Wellness Recovery Action Plan (WRAP) MS Word       02/01/2023
VR3381 Wellness Recovery Action Plan (WRAP) Services Summary and Recommendations MS Word       07/01/2021
VR3383 Supportive Residential Referral Form MS Word       02/01/2023
VR3384 Supportive Residential Services (SRS) Progress Report MS Word       02/01/2023
VR3386 Intensive Work Preparation and Life Skills Training Referral     PDF   11/01/2017
VR3387 Intensive Work Preparation and Life Skills Training Inventory     PDF   11/01/2017
VR3388 Intensive Work Preparation and Life Skills Training Individual Program Plan and Monthly Report     PDF   11/01/2017
VR3390 Intensive Work Preparation and Life Skills Training Family and Caregiver Support Training Plan MS Word       01/01/2018
VR3391 Intensive Work Preparation and Life Skills Training Staffing Report MS Word       01/01/2018
VR3406 Counseling Progress Report MS Word     MS Word 11/01/2017
VR3407 Training Progress Report MS Word   PDF   11/01/2017
VR3408 Vehicle Modification Evaluation MS Word       12/01/2020
VR3415 Workers' Compensation Contact Verification Letter MS Word     MS Word 02/01/2023
VR3420 Employment Support for Brain Injury - Referral MS Word       10/01/2019
VR3422 Reduced Payment Agreement MS Word       11/01/2017
VR3433 Mileage Premium Report MS Word       01/02/2019
VR3434 Provider Travel Plan and Report MS Word       03/15/2018
VR3436 Travel Premium Plan and Report MS Word       05/03/2021
VR3437 Hearing Aids and Accessories Certification MS Word       06/01/2022
VR3438 Vehicle Modification Certification MS Word       02/08/2021
VR3439 Durable Medical Equipment Certification MS Word       02/08/2021
VR3440A Goods and Equipment Part A - Parent Company Information MS Word       02/08/2021
VR3440B Goods and Equipment Part B - Local Business Location Information MS Word       12/01/2022
VR3441A Entity Headquarters Information Part A - Management Team MS Word       03/02/2020
VR3441B Entity Headquarters Information Part B - Services MS Word       11/01/2022
VR3441C Entity Headquarters Information Part C - Locations MS Word       12/01/2020
VR3442A Provider Physical Locations Part A - Certification Statement MS Word       12/01/2022
VR3442B Provider Physical Locations Part B - General Information MS Word       12/01/2022
VR3443 TWC VR Standards for Providers Certification MS Word       03/02/2020
VR3444 TWC VR Conflict of Interest Certification MS Word       03/02/2020
VR3445 Provider Insurance Verification MS Word       03/02/2020
VR3446 VR Incident Report MS Word       02/01/2023
VR3448 Employment Supports for Brain Injury - Provider Information and Acknowledgements MS Word       02/01/2023
VR3449 Employment Supports for Brain Injury - Professional Staff MS Word       11/02/2020
VR3454 Benefits Counseling Provider Staff Information Form MS Word       08/01/2022
VR3455 Provider Staff Information Form MS Word       11/01/2022
VR3472 Contracted Service Modification Request MS Word       02/01/2023
VR3472 Contracted Service Modification Request for Blind and Visually Impaired Services MS Word       02/01/2023
VR3472 Contracted Service Modification Request for Job Placement, Job Skills Training, and Supported Employment Services MS Word       02/01/2023
VR3472 Contracted Service Modification Request for Project SEARCH Services MS Word       02/01/2023
VR3472 Contracted Service Modification Request for Vocational Assessments MS Word       02/01/2023
VR3472 Contracted Service Modification Request for Work Experience Services MS Word       02/01/2023
VR3472 Contracted Service Modification Request for Work Readiness Services MS Word       02/01/2023
VR3473 Customer Orientation Checklist for VR Service Providers MS Word       02/01/2023
VR3490 Temporary Waiver of Credentials MS Word       06/01/2022
VR3494 Mechanic's Evaluation - Used Vehicle MS Word       11/01/2017
VR5053 Application Statement for Independent Living Services for Older Individuals Who are Blind (ILS-OIB) Program MS Word       10/01/2017
VR5053-S Declaración de Solicitud para el Programa de Servicios de Vida Independiente Para Adultos Mayors Ciegos (ILS-OIB) MS Word       10/01/2017
VR5056 Application for Vocational Rehabilitation Services MS Word       02/22/2022
VR5056-S Solicitud para Servicios Vocacionales de Rehabilitación MS Word       02/22/2022
VR5110 Refusal to Participate in TWS-VRS WIOA Section 511 Required Activities MS Word       10/01/2017
VR5110-S Rehusar Participar en Actividades Requeridas de TWS-VRS WIOA Sección 511 MS Word       10/01/2017
VR5111 Guardian Cover Letter MS Word       02/01/2023
VR5111-S Hoja de presentación del tutor MS Word       02/01/2023
VR5112 Career Counseling Datasheet MS Word       10/01/2017
VR5112-S Hoja de Datos de Asesoría para Carreras MS Word       10/01/2017
VR5113 Career Counseling and Information and Referral for Individuals – Subminimum Wage MS Word       10/01/2017
VR5113-S Orientación profesional e información y remisión para individuos - Salario inferior al mínimo MS Word       10/01/2017
VR5115 TWS-VRS Career Counseling Workbook MS Word       08/03/2020
VR5115-S TWC VRS Libro de Trabajo de Asesoría para Carreras MS Word       08/03/2020
VR5118 Section 511 Cover Sheet for Group Three MS Word       07/03/2018
VR5118-S Fracción 511 Hoja de Presentación para Grupo Tres MS Word       07/03/2018
VR5159 Individualized Plan for Employment (IPE) Amendment MS Word       02/08/2021
VR5159-S Plan Individualizado de Empleo (IPE) Enmendado MS Word       02/08/2021
VR5163 Individualized Plan for Employment (IPE) MS Word       02/08/2021
VR5163-S Plan de empleo individualizado MS Word       02/08/2021

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Last Verified: March 28, 2023

Equal Opportunity Employer/Program
Auxiliary aids and services are available upon request to individuals with disabilities.
Deaf, hard-of-hearing or speech-impaired customers may contact TWC through the relay service provider of their choice. Equal opportunity is the law.

For questions, compliments or complaints, call 800-628-5115

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