VR1020 |
TWC Substitute W-9 and Direct Deposit Form |
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|
 |
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06/27/2018 |
VR1020-S |
Forma W-9 Sustituta y de Depósito Directo del TWC |
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|
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09/01/2016 |
VR1021 |
Consumer or Parent Information and Direct Deposit |
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|
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|
08/01/2022 |
VR1021-S |
Información del Cliente o de los Padres/Guardas y de Depósito Directo |
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|
 |
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09/01/2016 |
VR1050 |
Ticket to Work Partnership Plus—Employment Advancement Payment |
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|
|
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10/01/2017 |
VR1200 |
Provider Feedback |
 |
|
|
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09/01/2022 |
VR1211 |
Provider Application |
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|
|
|
10/01/2017 |
VR1305 |
Child Support Certification |
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|
|
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11/01/2017 |
VR1307 |
Background Checks Attestation and Release Form |
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|
|
|
05/15/2023 |
VR1309 |
Contractor Notice of Appeal Rights |
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|
|
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07/01/2021 |
VR1487 |
Designation of Applicant or Customer Representative |
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|
|
|
10/01/2017 |
VR1487-S |
Designación del Representante del Solicitante o Cliente |
 |
|
|
|
10/01/2017 |
VR1505 |
Request for Due-Process Hearing and/or Mediation |
 |
|
 |
|
06/01/2021 |
VR1505-S |
Solicitud para audiencia de proceso debido y/o mediación |
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|
 |
|
06/01/2021 |
VR1512 |
Benefits and Work Incentives Planning Referral |
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|
|
|
02/01/2023 |
VR1600 |
Work Experience Services Referral |
 |
|
|
|
06/01/2022 |
VR1601 |
Work Experience Plan and Placement Report |
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|
|
|
06/26/2023 |
VR1604 |
Work Experience Training Report |
 |
|
|
|
05/15/2023 |
VR1609 |
On-the-Job Training Worksheet |
 |
|
|
|
10/13/2021 |
VR1628 |
Attendant Care Reimbursement—Request for Rate Exception |
|
|
 |
|
07/01/2015 |
VR1629 |
Referral for Career Planning Assessment (Replaced by VR5000) |
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|
|
|
06/26/2023 |
VR1630 |
Career Planning Assessment |
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|
|
|
02/01/2023 |
VR1631 |
Referral for Supported Employment Services (Replaced by VR5000) |
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|
|
|
06/26/2023 |
VR1632 |
Supported Employment Plan and Employment Report |
 |
|
|
|
02/01/2023 |
VR1633 |
Supported Employment Job Development and Job Analysis Report |
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|
|
|
02/01/2022 |
VR1634 |
Supported Employment Training Plan and Job Retention Report |
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|
|
|
02/01/2023 |
VR1640 |
Referral for Supported Employment Services |
 |
|
|
|
06/03/2019 |
VR1641 |
Supported Employment Assessment Report (SEA) |
 |
|
|
|
07/01/2021 |
VR1642 |
Supported Employment Services Plan 1 |
 |
|
|
|
09/01/2020 |
VR1643 |
Supported Employment Services Plan 2 - Placement, Job Analysis, and Training Plan |
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|
|
|
07/01/2021 |
VR1644 |
Supported Employment Services Time Tracking Log |
 |
|
|
|
09/01/2020 |
VR1645 |
Supported Employment Training and Progress Report |
 |
|
|
|
07/01/2021 |
VR1646 |
Supported Employment Job Stability Justification Summary |
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|
|
|
07/01/2021 |
VR1647 |
Supported Employment Services Closure Summary |
 |
|
|
|
07/01/2021 |
VR1800 |
Self-Employment Referral (Replaced by VR5000) |
|
|
|
|
06/26/2023 |
VR1801 |
Customer Profile and Self-Employment Exploration |
 |
|
|
|
02/01/2023 |
VR1802 |
Concept Development and Feasibility Study |
 |
|
|
|
02/01/2023 |
VR1803 |
Self-Employment Simple Business Plan |
 |
|
|
|
10/01/2017 |
VR1804 |
Self-Employment Comprehensive Business Plan |
 |
|
|
|
10/01/2017 |
VR1805-1 |
Self-Employment Financial Projections Spreadsheet (Statutory Blindness) |
|
 |
|
|
12/01/2022 |
VR1805-2 |
Self-Employment Financial Projections Spreadsheet |
|
 |
|
|
12/01/2022 |
VR1806 |
Self-Employment Financial Actual Spreadsheet |
|
 |
|
|
10/01/2017 |
VR1808 |
Supported Self-Employment Assessment (SSEA) |
 |
|
|
|
06/01/2022 |
VR1809 |
Supported Self-Employment Concept Development |
 |
|
|
|
02/01/2023 |
VR1810 |
Supported Self-Employment Feasibility Study |
 |
|
|
|
10/01/2017 |
VR1811 |
Supported Self-Employment Services Plan (SSESP) and Benchmark Report |
 |
|
|
|
02/01/2023 |
VR1812 |
Supported Self-Employment Business Plan Support Summary Report |
 |
|
|
|
02/01/2023 |
VR1813 |
Supported Self-Employment Business Plan |
 |
|
|
|
10/01/2017 |
VR1814 |
Supported Self-Employment Support Summary (SSE-SS) |
 |
|
|
|
02/01/2023 |
VR1815 |
Certified Business Technical Assistance Consultant (CBTAC) Support Summary Report |
 |
|
|
|
02/01/2023 |
VR1820 |
Request to Receive Pre-Employment Transition Services |
 |
|
|
|
12/01/2021 |
VR1820-S |
Solicitud para recibir servicios de transición previos al empleo |
 |
|
|
|
12/01/2021 |
VR1823 |
Pre-Employment Transition Services (Pre-ETS) Progress Report |
 |
|
|
|
02/01/2023 |
VR1824 |
Referral for Contracted Pre-Employment Transition Services (Pre-ETS) Services |
 |
|
|
|
02/01/2023 |
VR1825 |
Pre-ETS Curriculum Checklist |
 |
|
|
|
05/01/2023 |
VR1836 |
Vocational Evaluation Referral (Replaced by VR5000) |
|
|
|
|
06/26/2023 |
VR1837 |
Report for Vocational Evaluation |
 |
|
|
|
02/01/2023 |
VR1838 |
Situational Assessment and Work Sample Report |
 |
|
|
|
02/01/2023 |
VR1840 |
Job Placement Services - Referral (Replaced by VR5000) |
|
|
|
|
06/26/2023 |
VR1841 |
Non-Bundled Job Placement Services Data Sheet, Application, and Résumé Training |
 |
|
|
|
02/01/2023 |
VR1842 |
Non-Bundled Job Placement Services Interview Training Report |
 |
|
|
|
02/01/2023 |
VR1845A |
Bundled Job Placement Services Placement Plan Part A |
 |
|
|
|
02/01/2023 |
VR1845B |
Bundled Job Placement Services Plan Part B and Status Report |
 |
|
|
|
02/01/2023 |
VR1846 |
Bundled Job Placement Services Benchmark A Training Report |
 |
|
|
|
02/01/2023 |
VR1850 |
Employment Data Sheet |
 |
|
|
|
05/03/2021 |
VR1877A |
Environmental Work Assessment Report Part A |
 |
|
|
 |
10/01/2017 |
VR1877B |
Environmental Work Assessment Report Part B |
|
 |
|
|
11/01/2017 |
VR1877C |
Environment Work Assessment Signature Page Part C |
 |
|
|
|
10/01/2020 |
VR1878 |
Environmental Work Assessment Time Log |
 |
|
|
|
10/01/2017 |
VR1879 |
Referral Form for Services for Neurodevelopmental Disorders |
 |
|
|
|
07/01/2021 |
VR1880 |
Autism Spectrum Disorder Supports Plan |
 |
|
|
|
11/01/2018 |
VR1881 |
Autism Spectrum Disorder Supports Time Log and Progress Report |
 |
|
 |
|
10/01/2021 |
VR1882 |
Autism Service Premium Report |
 |
|
|
|
02/01/2023 |
VR1883 |
Blind Premium Report |
 |
|
|
|
11/01/2022 |
VR1884 |
Assistive Technology Services for Sight-Related Disabilities Referral |
 |
|
|
|
06/01/2022 |
VR1886 |
Assistive Technology Evaluation |
 |
|
|
|
02/01/2023 |
VR1888 |
Assistive Technology Training Results |
 |
|
|
|
02/01/2023 |
VR1990 |
Paid Work Experience Worksite Agreement |
 |
|
|
|
08/02/2021 |
VR1990-S |
Experiencia Laboral Remunerada Acuerdo sobre el lugar de trabajo |
 |
|
|
|
05/02/2022 |
VR1991 |
Referral for Embedded Pre-Employment Transition Services (Pre-ETS) (Replaced by VR5000) |
|
|
|
|
06/26/2023 |
VR1992 |
Embedded Pre-Employment Transition Services (Pre-ETS) Progress Report |
 |
|
|
|
02/01/2023 |
VR2006E |
Interagency Eye Examination Report |
 |
|
|
|
10/01/2017 |
VR2180 |
Maintenance Expense Log |
 |
|
 |
|
05/03/2021 |
VR2180-S |
Registro de gastos de mantenimiento |
 |
|
 |
|
05/03/2021 |
VR2181 |
Transportation Log |
 |
|
 |
|
05/03/2021 |
VR2181-S |
Registro de transporte |
 |
|
 |
|
05/03/2021 |
VR2305 |
Certificate of Medical Necessity Physician Order for Blood Pressure Monitor |
 |
|
|
|
09/03/2019 |
VR2868 |
Assistive Technology Training Report |
 |
|
|
|
02/01/2023 |
VR2883 |
Diabetes Self-Management Education Referral Form (Replaced by VR5000) |
|
|
|
|
06/26/2023 |
VR2884 |
Diabetes Self-Management Educator Notes |
 |
|
|
|
02/01/2023 |
VR2888 |
Diabetes Self-Management Education Assessment |
 |
|
|
|
02/01/2023 |
VR2889 |
Diabetes Self-Management Education Services - Adaptive Diabetes Equipment Receipt |
 |
|
|
|
06/03/2019 |
VR2891 |
ILS-OIB Customer Services Progress Report |
 |
|
|
|
02/01/2023 |
VR2894 |
Orientation and Mobility Assessment |
 |
|
|
|
02/01/2023 |
VR2896 |
Orientation and Mobility Training |
 |
|
|
|
09/18/2023 |
VR2897 |
Orientation and Mobility Referral |
 |
|
|
|
10/01/2017 |
VR2900 |
Diabetes Self-Management Education Post Training Assessment |
 |
|
|
|
02/01/2023 |
VR2901 |
Diabetes Self-Management Education Pre- and Post-Assessment |
 |
|
|
|
02/01/2023 |
VR2902 |
Assistive Technology Training Baseline Assessments |
 |
|
|
|
06/01/2022 |
VR2922 |
Orientation and Mobility Weekly Internship Observation |
 |
|
|
|
10/01/2017 |
VR2923 |
Orientation and Mobility Internship Performance Evaluation |
 |
|
|
|
10/01/2017 |
VR2954 |
Comprehensive Assessment for ILS-OIB Program |
 |
|
|
|
02/01/2023 |
VR3100 |
General Physical Examination Report |
 |
|
|
|
10/01/2017 |
VR3101 |
Consultant Review |
 |
|
 |
|
06/01/2021 |
VR3102 |
Pulmonary Evaluation Report |
 |
|
 |
|
11/01/2017 |
VR3103 |
Cardiac Evaluation Report |
 |
|
 |
 |
11/01/2017 |
VR3104 |
Acknowledgement for Noncertified Interpreter |
 |
|
 |
|
04/01/2022 |
VR3105A |
Hearing Evaluation Report: Customer Questionnaire |
 |
|
|
|
10/01/2017 |
VR3105A-S |
Informe de evaluación de la audición: Cuestionario para el cliente |
 |
|
|
|
10/01/2017 |
VR3105B |
Hearing Evaluation Report: Otological Examination |
 |
|
 |
|
06/01/2022 |
VR3105C |
Hearing Evaluation Report: Audiometric Examination |
 |
|
 |
|
10/01/2017 |
VR3105D |
Hearing Evaluation Report: Hearing Aid Recommendations |
 |
|
 |
|
03/01/2023 |
VR3105E |
Hearing Aid Fitting and Post-Fitting Report |
 |
|
|
|
01/15/2021 |
VR3105F |
Hearing Aid and Hearing Aid Accessories Return |
 |
|
|
|
06/01/2022 |
VR3106 |
Work Restriction Checklist |
 |
|
|
 |
11/01/2017 |
VR3108 |
Dental Report |
 |
|
 |
 |
11/01/2017 |
VR3109 |
Eye Surgery and Treatment Recommendations |
 |
|
|
|
12/01/2020 |
VR3110 |
Surgery and Treatment Recommendations |
 |
|
 |
|
08/27/2018 |
VR3111 |
End-Stage Renal Disease Evaluation |
 |
|
 |
 |
11/01/2017 |
VR3112 |
Cancer/Diabetes Disability Medical Report |
 |
|
|
|
08/01/2022 |
VR3118 |
Hospital Facility Information |
 |
|
|
|
06/01/2021 |
VR3121 |
Referral for Personal Social Adjustment Training and Work Adjustment Training |
 |
|
|
|
06/26/2023 |
VR3122 |
Vocational Adjustment Training (VAT): Explore the "You" in Work |
 |
|
|
|
02/01/2023 |
VR3123 |
Vocational Adjustment Training (VAT): Soft Skills for Work Success |
 |
|
|
|
02/01/2023 |
VR3124 |
Vocational Adjustment Training (VAT): Soft Skills to Pay the Bills |
 |
|
|
|
02/01/2023 |
VR3125 |
Vocational Adjustment Training (VAT): Entering the World of Work |
 |
|
|
|
02/01/2023 |
VR3126 |
Vocational Adjustment Training (VAT): Job Search Training |
 |
|
|
|
02/01/2023 |
VR3132 |
Vocational Adjustment Training (VAT): Disability Disclosure Training |
 |
|
|
|
02/01/2023 |
VR3133 |
Vocational Adjustment Training (VAT): Money Smart |
 |
|
|
|
02/01/2023 |
VR3134 |
Vocational Adjustment Training (VAT): Public Transportation Training |
 |
|
|
|
05/15/2023 |
VR3135A |
Vocational Adjustment Training Specialized Evaluation |
 |
|
|
|
02/01/2023 |
VR3135B |
Vocational Training Specialized Training Plan |
 |
|
|
|
02/01/2023 |
VR3136 |
Vocational Adjustment Training Specialized Progress Report |
 |
|
|
|
02/01/2023 |
VR3137A |
Personal Social Adjustment Training and Work Adjustment Training Evaluation |
 |
|
|
|
02/01/2023 |
VR3137B |
Personal Social Adjustment and Work Adjustment Training Plan |
 |
|
|
|
02/01/2023 |
VR3138 |
Personal Social Adjustment Training and Work Adjustment Training Report |
 |
|
|
|
02/01/2023 |
VR3139 |
Vocational Adjustment Training (VAT): Exploring Postsecondary Education and Training |
 |
|
|
|
02/01/2023 |
VR3141 |
Referral for Wage Services - WorkQuest |
 |
|
|
|
11/01/2021 |
VR3142 |
Worksite Agreement for Wage Services - WorkQuest |
 |
|
|
|
11/01/2021 |
VR3314 |
Job Skills Training Referral |
 |
|
|
|
02/01/2023 |
VR3315 |
Job Skills Training Progress Report |
 |
|
|
|
02/01/2023 |
VR3316 |
On-the-Job Training Progress Report |
 |
|
|
|
07/01/2021 |
VR3321 |
Proprietary School Training Information |
 |
|
|
|
11/01/2017 |
VR3360 |
Referral for Project SEARCH (Replaced by VR5000) |
|
|
|
|
06/26/2023 |
VR3361 |
Project SEARCH Asset Discovery Report |
 |
|
|
|
02/01/2023 |
VR3362 |
Project SEARCH Progress Report |
 |
|
|
|
02/01/2023 |
VR3363 |
Project SEARCH Job Placement Services Plan |
 |
|
|
|
02/01/2023 |
VR3364 |
Project SEARCH Placement Report |
 |
|
|
|
02/01/2023 |
VR3380 |
Referral for Wellness Recovery Action Plan (WRAP) (Replaced by VR5000) |
|
|
|
|
06/26/2023 |
VR3381 |
Wellness Recovery Action Plan (WRAP) Services Summary and Recommendations |
 |
|
|
|
07/01/2021 |
VR3383 |
Supportive Residential Referral Form (Replaced by VR5000) |
|
|
|
|
06/26/2023 |
VR3384 |
Supportive Residential Services (SRS) Progress Report |
 |
|
|
|
02/01/2023 |
VR3386 |
Intensive Work Preparation and Life Skills Training Referral |
|
|
 |
|
11/01/2017 |
VR3387 |
Intensive Work Preparation and Life Skills Training Inventory |
|
|
 |
|
11/01/2017 |
VR3388 |
Intensive Work Preparation and Life Skills Training Individual Program Plan and Monthly Report |
|
|
 |
|
11/01/2017 |
VR3390 |
Intensive Work Preparation and Life Skills Training Family and Caregiver Support Training Plan |
 |
|
|
|
01/01/2018 |
VR3391 |
Intensive Work Preparation and Life Skills Training Staffing Report |
 |
|
|
|
01/01/2018 |
VR3405 |
Tuition Payment Calculation Worksheet for Private or Out-of-State Training |
 |
|
|
|
07/20/2023 |
VR3406 |
Counseling Progress Report |
 |
|
|
 |
11/01/2017 |
VR3407 |
Training Progress Report |
 |
|
 |
|
11/01/2017 |
VR3408 |
Vehicle Modification Evaluation |
 |
|
|
|
12/01/2020 |
VR3415 |
Workers' Compensation Contact Verification Letter |
 |
|
|
 |
02/01/2023 |
VR3420 |
Employment Support for Brain Injury - Referral (Replaced by VR5000) |
|
|
|
|
06/26/2023 |
VR3422 |
Reduced Payment Agreement |
 |
|
|
|
11/01/2017 |
VR3433 |
Mileage Premium Report |
 |
|
|
|
01/02/2019 |
VR3434 |
Provider Travel Plan and Report |
 |
|
|
|
03/15/2018 |
VR3436 |
Travel Premium Plan and Report |
 |
|
|
|
05/03/2021 |
VR3437 |
Hearing Aids and Accessories Certification |
 |
|
|
|
06/01/2022 |
VR3438 |
Vehicle Modification Certification |
 |
|
|
|
02/08/2021 |
VR3439 |
Durable Medical Equipment Certification |
 |
|
|
|
02/08/2021 |
VR3440A |
Goods and Equipment Part A - Parent Company Information |
 |
|
|
|
02/08/2021 |
VR3440B |
Goods and Equipment Part B - Local Business Location Information |
 |
|
|
|
12/01/2022 |
VR3441A |
Entity Headquarters Information Part A - Management Team |
 |
|
|
|
03/02/2020 |
VR3441B |
Entity Headquarters Information Part B - Services |
 |
|
|
|
04/01/2023 |
VR3441C |
Entity Headquarters Information Part C - Locations |
 |
|
|
|
12/01/2020 |
VR3442A |
Provider Physical Locations Part A - Certification Statement |
 |
|
|
|
12/01/2022 |
VR3442B |
Provider Physical Locations Part B - General Information |
 |
|
|
|
12/01/2022 |
VR3443 |
TWC VR Standards for Providers Certification |
 |
|
|
|
03/02/2020 |
VR3444 |
TWC VR Conflict of Interest Certification |
 |
|
|
|
03/02/2020 |
VR3445 |
Provider Insurance Verification |
 |
|
|
|
03/02/2020 |
VR3446 |
VR Incident Report |
 |
|
|
|
02/01/2023 |
VR3447 |
Title IX Complaint |
 |
|
|
|
08/15/2023 |
VR3448 |
Employment Supports for Brain Injury - Provider Information and Acknowledgements |
 |
|
|
|
02/01/2023 |
VR3449 |
Employment Supports for Brain Injury - Professional Staff |
 |
|
|
|
11/02/2020 |
VR3454 |
Benefits Counseling Provider Staff Information Form |
 |
|
|
|
08/01/2022 |
VR3455 |
Provider Staff Information Form |
 |
|
|
|
04/01/2023 |
VR3472 |
Contracted Service Modification Request |
 |
|
|
|
02/01/2023 |
VR3472 |
Contracted Service Modification Request for Blind and Visually Impaired Services |
 |
|
|
|
02/01/2023 |
VR3472 |
Contracted Service Modification Request for Job Placement, Job Skills Training, and Supported Employment Services |
 |
|
|
|
02/01/2023 |
VR3472 |
Contracted Service Modification Request for Project SEARCH Services |
 |
|
|
|
02/01/2023 |
VR3472 |
Contracted Service Modification Request for Vocational Assessments |
 |
|
|
|
02/01/2023 |
VR3472 |
Contracted Service Modification Request for Work Experience Services |
 |
|
|
|
02/01/2023 |
VR3472 |
Contracted Service Modification Request for Work Readiness Services |
 |
|
|
|
02/01/2023 |
VR3473 |
Customer Orientation Checklist for VR Service Providers |
 |
|
|
|
02/01/2023 |
VR3490 |
Temporary Waiver of Credentials |
 |
|
|
|
06/01/2022 |
VR3494 |
Mechanic's Evaluation - Used Vehicle |
 |
|
|
|
11/01/2017 |
VR5000 |
Referral for Provider Services |
 |
|
|
|
06/26/2023 |
VR5053 |
Application Statement for Independent Living Services for Older Individuals Who are Blind (ILS-OIB) Program |
 |
|
|
|
10/01/2017 |
VR5053-S |
Declaración de Solicitud para el Programa de Servicios de Vida Independiente Para Adultos Mayors Ciegos (ILS-OIB) |
 |
|
|
|
10/01/2017 |
VR5056 |
Application for Vocational Rehabilitation Services |
 |
|
|
|
09/18/2023 |
VR5056-S |
Solicitud para Servicios Vocacionales de Rehabilitación |
 |
|
|
|
09/18/2023 |
VR5110 |
Refusal to Participate in TWS-VRS WIOA Section 511 Required Activities |
 |
|
|
|
10/01/2017 |
VR5110-S |
Rehusar Participar en Actividades Requeridas de TWS-VRS WIOA Sección 511 |
 |
|
|
|
10/01/2017 |
VR5111 |
Guardian Cover Letter |
 |
|
|
|
02/01/2023 |
VR5111-S |
Hoja de presentación del tutor |
 |
|
|
|
02/01/2023 |
VR5112 |
Career Counseling Datasheet |
 |
|
|
|
10/01/2017 |
VR5112-S |
Hoja de Datos de Asesoría para Carreras |
 |
|
|
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10/01/2017 |
VR5113 |
Career Counseling and Information and Referral for Individuals – Subminimum Wage |
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10/01/2017 |
VR5113-S |
Orientación profesional e información y remisión para individuos - Salario inferior al mínimo |
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10/01/2017 |
VR5115 |
TWS-VRS Career Counseling Workbook |
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08/03/2020 |
VR5115-S |
TWC VRS Libro de Trabajo de Asesoría para Carreras |
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08/03/2020 |
VR5118 |
Section 511 Cover Sheet for Group Three |
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07/03/2018 |
VR5118-S |
Fracción 511 Hoja de Presentación para Grupo Tres |
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07/03/2018 |
VR5159 |
Individualized Plan for Employment (IPE) Amendment |
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09/18/2023 |
VR5159-S |
Plan Individualizado de Empleo (IPE) Enmendado |
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09/18/2023 |
VR5163 |
Individualized Plan for Employment (IPE) |
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09/18/2023 |
VR5163-S |
Plan de empleo individualizado |
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09/18/2023 |