Table of Contents
Things You Should Know About This Form
What is the Iowa R 412 form?
The Iowa R 412 form is an application for Iowa Vocational Rehabilitation Services (IVRS). It is designed to gather important personal information from individuals seeking assistance with vocational rehabilitation. The form covers various aspects, including personal details, disability information, transportation needs, and employment history.
Who should fill out the Iowa R 412 form?
Individuals who are seeking vocational rehabilitation services in Iowa should complete the Iowa R 412 form. This includes those with disabilities who require support in finding or maintaining employment. If someone needs assistance in filling out the form, they are encouraged to seek help.
What information is required on the form?
The form requires a variety of information, including:
- Personal details such as name, address, and contact information.
- Disability information, including the nature of the disability and its impact on work.
- Transportation details, including how the individual travels and any accessibility needs.
- Employment history and education background.
Completing all sections is important for the application to be processed effectively.
Can I use additional paper if I run out of space on the form?
Yes, if you need more space to provide your answers, you can use an additional piece of paper. It is important to ensure that all relevant information is included to avoid delays in processing your application.
What if I have a legal guardian?
If you have a legal guardian, it is important to include their name and contact information on the form. This allows IVRS to communicate effectively with your guardian regarding your application and any services you may need.
What happens after I submit the Iowa R 412 form?
After submitting the form, the IVRS will review your application. They may reach out for additional information or clarification if needed. Once your application is processed, you will be contacted regarding the next steps in receiving services.
Is there a deadline for submitting the Iowa R 412 form?
There is no specific deadline for submitting the Iowa R 412 form. However, timely submission is encouraged to ensure that you receive the necessary support as soon as possible. Delays in submitting the form may affect the speed at which services can be provided.
How can I contact IVRS for assistance with the form?
You can contact Iowa Vocational Rehabilitation Services directly for assistance with the Iowa R 412 form. They can provide guidance on filling out the form and answer any questions you may have about the application process. Their contact information can usually be found on their official website.
Form Features
| Fact Name | Fact Description |
|---|---|
| Form Purpose | The Iowa R 412 form is an application for Iowa Vocational Rehabilitation Services, aimed at assisting individuals with disabilities in gaining employment. |
| Personal Information | Applicants must provide personal details, including name, address, date of birth, and social security number, to ensure proper identification and processing. |
| Disability Information | Section C requires applicants to disclose their disability or condition, medications, and how their disability affects their work capabilities. |
| Transportation Needs | Transportation information is essential. Applicants indicate their mode of transportation and whether their job needs to be accessible by bus. |
| Support and Benefits | Section E asks about any public support the applicant receives, such as Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI). |
| Criminal Background | In Section F, applicants must disclose any criminal convictions and their potential impact on job opportunities. |
| Education History | Applicants provide details on their educational background, including the highest grade completed and any special education services received. |
| Employment History | Section H requires information about current and past employment, including job titles, duties, and reasons for leaving previous jobs. |
| Legal Authority | The Iowa R 412 form is governed by Iowa Code Chapter 259, which outlines the state's vocational rehabilitation services. |
| Assistance Availability | The form encourages applicants to seek help if needed, emphasizing that support is available throughout the application process. |
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Key takeaways
Understanding the Iowa R 412 Form is essential for those seeking assistance from Iowa Vocational Rehabilitation Services (IVRS). Here are some key takeaways regarding the form:
- Complete All Sections: Ensure that every part of the form is filled out thoroughly. Incomplete forms can delay the application process.
- Seek Assistance: If you encounter difficulties while filling out the form, do not hesitate to ask for help. Support is available to guide you through the process.
- Provide Accurate Information: Be truthful and precise when detailing personal information, disability status, and employment history. This information is crucial for determining eligibility and the types of services you may receive.
- Transportation Details Matter: Clearly indicate your transportation options and any accessibility needs. This information can affect job placement and support services.
- Be Prepared for Follow-Up: After submitting the form, be ready for potential follow-up questions or requests for additional information. Keeping your contact details updated will facilitate communication.
Sample - Iowa R 412 Form
Iowa Vocational Rehabilitation Services – Application Form
Please complete all sections. If you would like assistance with this form, do not hesitate to ask. If you need more space, please use an additional piece of paper.
A. Personal Information:_____________________________________________________________
First Name: ________________________________________________________________________
Middle/Maiden: _____________________________________________________________________
Last Name:_________________________________________________________________________
Social Security Number:____________________________ Date of Birth:_______________________
Home Address:______________________________________________________________________
City: ______________________________________State:_____________Zip:___________________
County:_____________________ Phone: (Home) (___)_______________ (Cell)(___)_____________
Race: Please check all that apply.
____White _____Native Hawaiian or Other Pacific Islander _______Asian
____American Indian or Alaska Native ______Black or African American
Ethnicity: Please check one.
Hispanic or Latina: ___ Yes ___ No
Marital Status: Please check at least one.
____Married, including common law ____Widowed ____Divorced ____ Separated
____Never Married
Living Arrangements:
___Private Residence ___Community Residence or Group Home ___Rehabilitation Facility
___Mental Health Facility ___Nursing Home ____Halfway House ____Homeless Shelter
___Substance Abuse Treatment Center ____Adult Correctional Facility ____Other
Do you have a legal guardian? _____Name:_____________________ Phone:_________________
Cultural/Religious Preferences:
Are there cultural or religious preferences we should be aware of that may affect vocational planning?
___ Yes ___ No
_________________________________________________________________________________
B. Referral Source and Rehabilitation Services:________________________________________
What services would you like to receive from Iowa Vocational Rehabilitation Services (IVRS)?
_______________________________________________________________________________
________________________________________________________________________________
Who referred you to IVRS?______________________________ Phone Number:(___)_____________
Is there someone outside of your household who would usually be able to help us contact you? First Name: _________________Last Name:_________________ Relationship:_______________
Phone: (Home):(___)____________ (Mobile):(___)______________ (Work):(___)_____________
City:_______________________________________ State: ______________ Zip: _____________
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First Name: _________________Last Name:_________________ Relationship:_______________
Phone: (Home):(___)____________ (Mobile):(___)______________ (Work):(___)_____________
City:_______________________________________ State: ______________ Zip: _____________
C. Disability Information:____________________________________________________________
What is your disability, condition, or diagnosis?_________________________________________
________________________________________________________________________________
________________________________________________________________________________
What medications are you currently taking?
________________________________________________________________________________
________________________________________________________________________________
Do you take your medication as prescribed?_____ yes ____no, if no explain:__________________
________________________________________________________________________________
How does your disability affect your ability to work or find work?__________________________
________________________________________________________________________________
________________________________________________________________________________
D.Transportation Information:_______________________________________________________
What type of transportation do you use? (check all that apply) ____private vehicle ____bus
____taxi ____family/friends ____other: please explain: __________________________________
Would any job that you obtain need to be accessible by bus (route and schedule)? ___ yes ___ no Do you have an alternative plan for transportation in case of an emergency? _____ yes ______ no
Describe the alternative plan:_______________________________________________________
Do you have a valid driver’s license? ___ yes ___ no
If no, do you plan to get a driver’s license? ____ yes ____ no
Do you plan to take driver’s education if you do not currently have a driver’s license? __yes ___ no
Do you have a Chauffeur’s or CDL license? ___yes ___ no
E. Monthly Support and Benefits at Application:________________________________________
Have you ever applied for Social Security Disability or Supplemental Security Income? ___yes___no If so, what were the results? ___approved ___denied ___pending ____in appeal process
If you are receiving public support, please enter whole dollar amounts next to the benefit you receive:
__________SSDI |
__________SSI |
__________TANF __________Veteran’s Disability |
|
__________General Assistance |
__________Worker’s Compensation |
||
__________Other Public Support (specify_____________________________________________)
What is your primary source of support? ____ personal income (earnings, interest, etc.)
______Family/Friends |
_____Public Support (SSI, SSDI, TANF, etc) ___All Other Sources |
||
What source of health insurance do you use? (check all that apply) |
|||
____Current Job |
____Medicaid |
____Medicare ____Public Insurance from Other sources |
|
____ No Health Insurance |
_____Private (Health Insurance Company:_______________________ |
||
) |
|
|
|
F. Reported Criminal Background:____________________________________________________
Do you anticipate problems with a background check? ___yes ___no
Have you ever been convicted of a crime? ___ yes ___ no
If yes, explain:______________________________________________________________
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What was the outcome of the conviction (parole, prison time, under
_________________________________________________________________________________
What is the impact on your vocational choices and are there specific jobs you will not be able to do?
__________________________________________________________________________________
G.Education Information at Application:_______________________________________________
What is the highest grade you completed? _______________
Did you receive special education services while in high school?____yes ____ no
If Yes, when (month/year) did you begin special education services? _______
Did you receive services in high school under a 504 plan? ______yes ______ no
While in high school are you, or did you participate, in a work experience program? ____ yes ____ no Are you planning on pursuing further training? ____ yes ____no (if yes, please describe the program and or school:______________________________________________________________________)
If you have plans to pursue an education beyond high school:
Have you received the Free Application for Federal Student Aid (FAFSA)?___ yes ___ no Have you applied for student financial aid? ___yes ___ no
Are you in default of a federal student loan?____ yes ____ no
Are there any personal problems or circumstances that might interfere with you working while attending school? (If yes, please explain) ____yes ____no Explain:____________________________
__________________________________________________________________________________
Education History:
Name and Location of High School:_____________________________________________________
High School Student ID Number, if currently a high school student in Iowa: _____________________
Month and Year Graduated:_____________________________ (may be a future target date)
…………………………………………………………………………………………………………..
Last College or Vocational Training School Attended:_______________________________________
School Location: ____________________________ Completed Program?____ yes ____no
If you did not complete the program please explain why:_____________________________________
__________________________________________________________________________________
Major or Program:_________________________________Degree/Certificate:___________________
Dates Attended: from____________ to ____________ GPA:____________
…………………………………………………………………………………………………………….
Other College or Vocational Training School Attended:______________________________________
School Location: ____________________________ Completed Program?____ yes ____no
If you did not complete the program please explain why:_____________________________________
__________________________________________________________________________________
Major or Program:_________________________________Degree/Certificate:___________________
Dates Attended: from____________ to ____________ GPA:____________
H. Employment History:_____________________________________________________________
Are you currently employed? ___yes ___ no
Employer:_________________________________ Job Title:_________________________________
Address:___________________________________City:________________State:_______Zip:_____
Wage:_________per _______(hour, week, biweekly, bimonthly, year)
Hours Per Week:___________ Date Began:__________________
Specific Duties:_____________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
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Other Experience:
Have you served in the military? ___yes ___ no
If yes, ____ Honorable discharge ____ Dishonorable Discharge
If Dishonorable Discharge, please explain: _______________________________________________
Have you had jobs other than the one listed above? If so please provide the following information:
Employer:__________________________________ Job Title:_______________________________
Address: ___________________________________City_____________State:__________Zip:_____
Date Began:_______month _______year Date Ended: ________month _________ year
Direct Supervisor: _________________________________________ Phone: ___________________
Specific Duties:_____________________________________________________________________
__________________________________________________________________________________
Reason for Leaving: ___change jobs ___further education ____relocated ____company went out of
business ____laid off (explain:________________________________________________________)
_____fired (explain:________________________________________________________________)
_____other________________________________________________________________________)
Will this employer provide a good reference for you? ___ yes ___ no (if no, what do you think the employer will say?_________________________________________________________________)
………………………………………………………………………………………………………….
Employer:__________________________________ Job Title:_______________________________
Address: ___________________________________City_____________State:__________Zip:_____
Date Began:_______month _______year Date Ended: ________month _________ year
Direct Supervisor: _________________________________________ Phone: ___________________
Specific Duties:_____________________________________________________________________
__________________________________________________________________________________
Reason for Leaving: ___change jobs ___further education ____relocated ____company went out of
business ____laid off (explain:________________________________________________________)
_____fired (explain:________________________________________________________________)
_____other________________________________________________________________________)
Will this employer provide a good reference for you? ___ yes ___ no (if no, what do you think the employer will say?_________________________________________________________________)
………………………………………………………………………………………………………….
Employer:__________________________________ Job Title:_______________________________
Address: ___________________________________City_____________State:__________Zip:_____
Date Began:_______month _______year Date Ended: ________month _________ year
Direct Supervisor: _________________________________________ Phone: ___________________
Specific Duties:_____________________________________________________________________
__________________________________________________________________________________
Reason for Leaving: ___change jobs ___further education ____relocated ____company went out of
business ____laid off (explain:________________________________________________________)
_____fired (explain:________________________________________________________________)
_____other________________________________________________________________________)
Will this employer provide a good reference for you? ___ yes ___ no (if no, what do you think the employer will say?_________________________________________________________________)
…………………………………………………………………………………………………………..
Do you have the documents necessary to comply with Form
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Similar forms
The Iowa R 412 form shares similarities with the Social Security Administration (SSA) Disability Application. Both documents require detailed personal information, including the applicant's name, Social Security number, and contact details. They also seek information about the applicant's disability, its impact on their daily life, and their work capabilities. The SSA application is specifically focused on determining eligibility for disability benefits, while the Iowa R 412 form is geared towards vocational rehabilitation services.
For individuals looking to bolster their legal preparedness, the essential Durable Power of Attorney document provides a vital framework for designating an agent to manage their affairs in times of need. This document ensures that preferences are honored and responsibilities are efficiently managed, safeguarding one's interests with clarity and authority.
Another document akin to the Iowa R 412 is the Supplemental Nutrition Assistance Program (SNAP) application. Like the Iowa R 412, the SNAP application requires personal details, including income sources and household composition. Both forms assess the applicant's need for support services. While the Iowa R 412 focuses on vocational rehabilitation, SNAP aims to determine eligibility for food assistance.
The Iowa R 412 form is also similar to the Medicaid application. Both require applicants to disclose personal information, including income and resources. They assess eligibility based on financial need and disability status. The primary difference lies in their objectives; the Iowa R 412 seeks to provide vocational support, whereas Medicaid focuses on health care assistance.
Additionally, the form is comparable to the Temporary Assistance for Needy Families (TANF) application. Both documents collect information about the applicant's family situation, income, and any disabilities. They aim to determine eligibility for financial assistance. TANF provides temporary financial support, while the Iowa R 412 is designed to assist with vocational rehabilitation services.
The Iowa R 412 form resembles the Employment Authorization Document (EAD) application. Each requires personal identification details, including Social Security numbers and contact information. Both forms assess the applicant's legal status to work in the United States. However, the EAD application is specifically for individuals seeking permission to work, while the Iowa R 412 focuses on rehabilitation services for those with disabilities.
Another similar document is the Federal Student Aid (FAFSA) application. Both forms require detailed personal and financial information. They assess eligibility for different types of assistance—FAFSA for educational funding and the Iowa R 412 for vocational rehabilitation. Each aims to support individuals in achieving their goals, whether in education or employment.
The Iowa R 412 form can also be compared to the Worker’s Compensation claim form. Both documents collect information about the individual’s employment history and any disabilities or conditions affecting their work. They are designed to assess eligibility for support related to work-related injuries or disabilities. The primary distinction is that Worker’s Compensation focuses on compensation for injuries, while the Iowa R 412 addresses vocational rehabilitation needs.
Similarly, the Unemployment Insurance application shares commonalities with the Iowa R 412. Both require personal information, including work history and reasons for unemployment. They assess the individual's need for financial support while seeking new employment. However, the Iowa R 412 specifically targets those with disabilities seeking vocational rehabilitation services.
The Iowa R 412 form is also akin to the Individualized Education Program (IEP) documentation. Both require detailed information about the individual's educational history and any disabilities. They aim to provide tailored support, whether in a school setting or through vocational rehabilitation. The IEP focuses on educational needs, while the Iowa R 412 addresses vocational goals.
Lastly, the form is similar to the Veterans Affairs (VA) disability benefits application. Both documents require personal information, including disability status and its impact on daily life. They assess eligibility for support services. While the VA application is specific to veterans seeking disability benefits, the Iowa R 412 is focused on providing vocational rehabilitation services to individuals with disabilities.