All these forms are available in System 6. The asterisk indicates that coding information is available within System 6 through function key one.
A. (Call or Close Letter)
Department of Labor and Economic Growth
MICHIGAN COMMISSION FOR THE BLIND
CLIENT SERVICES DIVISION
STREET
CITY, STATE ZIP
PHONE
DATE
PREFIX First Name Last Name
STREET
STREET2
CITY, STATE ZIP
Dear First Name,
When you applied for services we agreed on the importance of staying in close touch. Since then I have tried to reach you multiple times both by phone and letter. I have not received any response. Therefore, if I do not hear from you in the next ten (10) days I will presume that you are no longer interested in vocational rehabilitation services from this agency and will close your case. If you are still interested in our services, please get in touch with me.
Sincerely,
FIRST NAME LAST NAME
B. Initial Information - VR Form
Department of Labor and Economic Growth
MICHIGAN COMMISSION FOR THE BLIND
CLIENT SERVICES DIVISION
STREET, CITY, STATE ZIP
PHONE
INITIAL INFORMATION - VR
Last: First: MI:
Street:
Additional: City:
County*: Zip*:
Phone:
Birthdate:
Marital Status*
Staff:
Date of Referral:
Referral Source*:
Disability Information:
Primary*
Secondary*
Other*
Significantly Disabled*
At Application:
Education Level*
Residence*
Work Status*
Previously Employed?
Year Last Employed:
Hours of Paid Work During Previous Week*
Gross Earnings During Previous Week:
Primary Source of Support*
Medical Insurance Coverage*
Insurance Available from an Employer*
Type of Medical Insurance
Public Support (Y=Yes N=No):
SSI Aged?
SSI Blind?
SSI Disabled?
Temporary Assistance for Needy Families (TANF)?
General Assistance?
Social Security Disability Insurance?
Veteran's Disability Benefits?
Other Disability Benefits?
All Other Public Support Payments?
Total amount of SSI, TANF, & General Assistance:
Worker's Compensation?
Honorably Discharged Veteran?
Public safety Officer injured in line of duty?
Deaf/Blind?
Migratory Agricultural Worker?
Projects with Industry?
Supported Employment Planning Information:
Funding Source*
Case Manager for funding source
Phone number at funding source
C. Closure form
Department of Labor and Economic Growth
MICHIGAN COMMISSION FOR THE BLIND
CLIENT SERVICES DIVISION
STREET
CITY, STATE ZIP
PHONE
Client:
Counselor:
CLOSURE FORM
You are considered to be successfully rehabilitated in that you have maintained satisfactory employment for at least 90 days.
Job Title*:
Wages:
Benefits:
Employer*:
Employer's Address
Street:
City: State: Zip:
The following services contributed to your success:
This employment is commensurate with your abilities, capabilities, interests and informed choice.
This employment is in the most integrated setting possible, consistent with your informed choice.
You and I agree that your employment outcome is satisfactory and that you are performing well on the job.
You and I have assessed the need for post-employment services and have agreed on the following services and how they will be provided:
You are also aware that unplanned post-employment services are available if necessary to maintain your employment.
As indicated in your application, if you are dissatisfied with any determination made by your vocational rehabilitation staff person, you may request an Administrative Review with your counselor's supervisor or you may request a formal hearing by contacting the Michigan Commission for the Blind Hearing Coordinator at 517-373-2062. Please be reminded that you may receive assistance from the Protection and Advocacy Service at 1-800-292-5896.
Client's Signature: Date:
(or Designee)
Counselor's Signature: Date:
D. Demographic Form
Department of Labor and Economic Growth
MICHIGAN COMMISSION FOR THE BLIND
CLIENT SERVICES DIVISION
STREET
CITY, STATE ZIP
PHONE
DEMOGRAPHIC INFORMATION
Title*: Last: First: M.I.: Birthdate:
Residential Address:
Street:
City:
County*:
State: Zip:*
Directions to home:
Mailing Address (if different):
Address:
City:
State: Zip*:
Contacts:
Home Phone:
Work Phone:
Fax:
E-Mail:
Preferred Communication form:*
Manual Communication? TDD?
Contact Person: Contact Phone:
Other Information:
Sex M/F:
Race*
Hispanic?
Arab-American-Chaldean?
English speaking?
If No, language used:
Registered voter?
If No, want to register?
School-to-Work Student?
Location*
School contact information:
Caseload Manager/Number*:
Office Number*:
E. Diagnostic Service Authorization
Department of Labor and Economic Growth
MICHIGAN COMMISSION FOR THE BLIND
CLIENT SERVICES DIVISION
STREET, CITY, STATE ZIP
PHONE
DIAGNOSTIC SERVICE AUTHORIZATION
AUTHORIZATION #: Date Issued:
Budget Account*:
Client:
Vendor SSN*:
Vendor Name:
Pay to Number:
Address:
Description of Service*:
Service Dates: Thru
Serv. Type:
Unit Price:$ per Unit: No. Units: Amt:$
Service detail:
Agency Object:
Void After:
Total amount authorized: $
Authorized Signature:
Authorizer's Name:
Please Submit invoices to the authorizer and Address above. Authorization is hereby given to provide the services describe above. Payment can only be made for the services authorized and at the rates authorized. If there is any change required in this authorization the Vendor must contact the authorizer first. Payment will be made promptly upon receipt of properly prepared invoices.
Authority: P. A. 260 of 1978, as amended Index:
Completion: Mandatory PCA:
Penalty: Services may not be provided
F. Eligibility form
Department of Labor and Economic Growth
MICHIGAN COMMISSION FOR THE BLIND
CLIENT SERVICES DIVISION
STREET
CITY, STATE ZIP
PHONE
Client:
Counselor:
CERTIFICATION OF ELIGIBILITY
The above individual has the following impairments:
These impairments result in the following functional limitations and significant impediment to employment:
This individual can benefit from the following services:
It is presumed that this individual can benefit in terms of an employment outcome.
Counselor's Signature: Date:
G. Eye Exam Report
Department of Labor and Economic Growth
MICHIGAN COMMISSION FOR THE BLIND
CLIENT SERVICES DIVISION
STREET
CITY, STATE ZIP
PHONE
Client:
Address: Phone:
Birthdate: Sex (m/f):
Counselor:
EYE EXAMINATION REPORT
NOTE TO EXAMINER
You are hereby authorized to release the information requested below to the Michigan Commission for the Blind (MCB). This exam is at the patient's expense unless this form is accompanied by an MCB Service Authorization.
Client Signature: Date:
(or Designee)
1. History:
A. Age at onset of significant visual defect:
B. Injuries, infections, surgeries, hereditary factors:
2. Diagnosis:
R.E.:
L.E.:
3. Describe Abnormal Findings:
R.E.:
L.E.:
4. Intraocular Pressure in mm. Hg. (specify instrument used)
R.E.:
L.E.:
5. Vision Measurements:
Without Correction: Distance: R.E.: 20/ L.E.: 20/
Near: R.E.: 20/ L.E.: 20/
With Correction: Distance: R.E.: 20/ L.E.: 20/
Near: R.E.: 20/ L.E.: 20/
Correction Needed:
RE:
L.E.:
Addition:
6. Peripheral Field of Vision: Provide a verbal description of visual fields and
attach copies of the charts, if available.
7. Prognosis ("X" appropriate terms):
Patient's vision is considered ("X" appropriate terms) – Stable:
Deteriorating:
Capable of improvement:
Uncertain:
8. Treatment Recommended:
9. Functional limitations caused by visual condition:
The following 3 criteria substantiate a disability for purposes of determining eligibility for rehabilitation services from MCB (please check all that apply):
1. Visual acuity in the better eye is 20/200 or less with best
correction.
2. Visual fields are limited to subtending an angular distance not greater than 20 degrees.
3. Visual acuity is 20/100 or less in the better eye with a progressively worsening condition.
(Please print clearly or type)
Examiner:
Address: Phone:
Examiner's Signature: Date:
Authority: P.A. 260, as amended: Completion: Mandatory
Penalty: Non-payment of Service
ALL SERVICES WILL BE AVAILABLE TO INDIVIDUALS REGARDLESS OF RACE, SEX, RELIGION, AGE, NATIONAL ORIGIN, COLOR, MARITAL STATUS, IMPAIRMENT OR POLITICAL BELIEF
H. General Medical Form
Department of Labor and Economic Growth
MICHIGAN COMMISSION FOR THE BLIND
CLIENT SERVICES DIVISION
STREET, CITY, STATE ZIP
PHONE
Client:
Address: Phone:
Birthdate: Sex (m/f):
Counselor:
GENERAL MEDICAL EXAMINATION REPORT
NOTE TO EXAMINER
You are hereby authorized to release the information requested below to the Michigan Commission for the Blind (MCB). This exam is at the patient's expense unless this form is accompanied by a MCB Service Authorization.
Client Signature: Date:
1. History of disabling condition:
2. General Inspection:
3. Height: Weight: Pulse Rate:
Blood Pressure: Cardiac Rhythm:
4. Findings ("X" only if abnormal):
()Head & Neck -- Eyes ()Ears ()Nose and throat
()Thyroid ()Lungs ()Cervical Nodes
()Chest – Heart ()Abdomen - Masses
()Hernia ()Genitor – Urinary ()Rectum
()Extremities -- Weakness ()Paralysis ()Amputation
()Neuro-Muscular – Speech ()Gait ()Reflexes
()Tremors ()Coordination
()Mental State – Emotional Stability ()Mentality
5. Laboratory Studies:
()Urine – Date: ()Albumen ()Sugar
()Blood – Date: ()HGB: ()Serology
6. Diagnosis:
7. Characteristics of Impairment ("X" appropriate terms):
STATUS: ()Improving
()Stable
()Deteriorating
PROGNOSIS: ()Remediable by treatment
()Improvement by treatment
()Not Remediable
()Terminal
8. Lifting/Carrying Restrictions ("X" appropriate terms):
0-5 lbs. Never: () Occasionally: () Frequently: ()
6-10 lbs. Never: () Occasionally: () Frequently: ()
11-20lbs. Never: () Occasionally: () Frequently: ()
21-25 lbs. Never: () Occasionally: () Frequently: ()
26-50 lbs. Never: () Occasionally: () Frequently: ()
51-100 lbs. Never: () Occasionally: () Frequently: ()
9. Standing, Walking & Sitting:
Please estimate the hours that our client might tolerate the following activities
during a workday:
Standing hours/day
Walking hours/day
Sitting hours/day
10. Additional Functional Limitations (i.e. driving, bending, climbing
exposure to dust, exposure to fumes, etc.):
11. Medication (please specify type, dosage, schedule and potential side
effects):
12. Recommendations (please indicate any additional diagnostic studies,
treatments or referrals to specialists necessary):
(Please print clearly or type)
Examiner:
Address: Phone:
Examiner's Signature: Date:
Authority: P.A. 260, as amended: Completion: Mandatory
Penalty: Non-payment of Service
ALL SERVICES WILL BE AVAILABLE TO INDIVIDUAL REGARDLESS OF RACE, RELIGION, AGE, NATIONAL ORIGIN, COLOR, MARITAL STATUS, IMPAIRMENT OR POLITICAL BELIEF
I. Individual Plan for Employment – Amendment Form
Department of Labor and Economic Growth
MICHIGAN COMMISSION FOR THE BLIND
CLIENT SERVICES DIVISION
STREET, CITY, STATE ZIP
PHONE
Client:
Counselor:
INDIVIDUAL PLAN FOR EMPLOYMENT – AMENDMENT
The following are changes to your Individual Plan for Employment agreed upon between you and me:
Service*:
Beginning Date: Ending Date:
Vendor:
Sponsor*:
Cost to MCB:
All other aspects of your plan remain the same.
If you are dissatisfied with any determination made by a staff person, you may request an administrative review with that individual's supervisor or you may request a formal hearing by contacting the MCB Hearing Coordinator in writing or by phoning 517-373-3062.
You may contact the Michigan Protection and Advocacy office if you want assistance or representation at an administrative review or hearing. You may contact them at 1-800-292-5896.
Client's (or Designee)Signature: Date:
Counselor's Signature: Date:
J. Individual Plan for Employment Form
Department of Labor and Economic Growth
MICHIGAN COMMISSION FOR THE BLIND
CLIENT SERVICES DIVISION
STREET, CITY, STATE ZIP
PHONE
Client: FirstName LastName
Counselor: FNAME LNAME
INDIVIDUALIZED PLAN FOR EMPLOYMENT (IPE)
DOT Code*:
Vocational Goal:
Anticipated Date of Achievement:
Preferred Mode of Communication*:
Consumers may complete this IPE on their own or request technical assistance from a rehabilitation counselor to complete it.
This Individualized Plan for Employment shall be developed and implemented in a manner that affords eligible individuals the opportunity to exercise informed choice in selecting an employment outcome, the specific vocational rehabilitation services to be provided under the plan, the entity that will provide the services, and the methods used to procure the services.
OUTLINE OF SERVICES
Service*:
Beginning Date: FROM Ending Date:
Vendor:
Sponsor*:
Cost to MCB:
To the maximum extent appropriate, the vocational goal and services outlined in this IPE will occur in the most integrated setting.
The following criteria will be used to evaluate progress towards the achievement of the employment outcome:
The agency will have the following responsibilities in implementing this plan:
The consumer will have the following responsibilities in implementing this plan:
The following comparable benefits are available:
In a supported employment situation, long-term follow along services will be provided by:
If you are dissatisfied with any determination made by a staff person, you may request an administrative review with that individual's supervisor or you may request a formal hearing by contacting the MCB Hearing Coordinator in writing or by phoning 517-373-2062.
You may contact the Michigan Protection and Advocacy office if you want assistance or representation at an administrative review or hearing. You may contact them at 800-292-5896.
Client's (or Designee) Signature: Date:
Counselor's Signature: Date:
K. Referral Form
Department of Labor and Economic Growth
MICHIGAN COMMISSION FOR THE BLIND
CLIENT SERVICES DIVISION
STREET
CITY, STATE ZIP
PHONE
Client:
Address: Phone:
Counselor:
REFERRAL FORM
The above named individual is being referred for the following services:
Reason For Referral:
Pertinent Background Information:
Attachments:
Counselor's Signature: Date:
L. Rehabilitation Teacher Diagnostic Report Form
Department of Labor and Economic Growth
MICHIGAN COMMISSION FOR THE BLIND
CLIENT SERVICES DIVISION
STREET, CITY, STATE ZIP
PHONE
Client:
Counselor:
REHABILITATION TEACHING DIAGNOSTIC REPORT
MOBILITY
Functional Limitation:
Recommendation:
COMMUNICATIONS
Functional Limitations:
Recommendations:
SELF CARE
Functional Limitations:
Recommendations:
SELF DIRECTION
Functional Limitation:
Recommendations:
INTERPERSONAL SKILLS
Functional Limitations:
Recommendations;
WORK TOLERANCE
Functional Limitations:
Recommendations:
WORK SKILLS
Functional Limitations:
Recommendations:
ADDITIONAL COMMENTS
Rehabilitation Teacher: Date:
M. Rehabilitation Teaching Progress Report Form
Department of Labor and Economic Growth
MICHIGAN COMMISSION FOR THE BLIND
CLIENT SERVICES DIVISION
STREET, CITY, STATE ZIP
PHONE
Client:
Counselor:
REHABILITATION TEACHING PROGRESS REPORT
MOBILITY
Objective:
Progress:
COMMUNICATIONS
Objectives:
Progress:
SELF CARE
Objectives:
Progress:
SELF DIRECTION
Objectives:
Progress:
INTERPERSONAL SKILLS
Objectives:
Progress:
WORK TOLERANCE
Objectives:
Progress:
WORK SKILLS
Objectives:
Progress
ADDITIONAL COMMENTS
Rehabilitation Teacher: Date:
N. Release of Information Form
Department of Labor and Economic Growth
MICHIGAN COMMISSION FOR THE BLIND
CLIENT SERVICES DIVISION
STREET, CITY, STATE ZIP
PHONE
Client: LastName, FirstName
Address: STREET Phone: TELEPHONE
STREET2
CITY, STATE ZIP
Birthdate: Birthdate Sex (m/f):
Counselor: FNAME LNAME
AUTHORIZATION FOR RELEASE OF INFORMATION
TO WHOM IT MAY CONCERN:
You are hereby authorized to furnish the following specific information to the Michigan Commission for the Blind:
This authorization is good until:
Please send the information to my counselor at the office address above.
Sincerely,
Client Signature: Date:
(or Designee)
Authority: P.A. 260, as amended: Completion: Mandatory
Penalty: Non-payment of Service
ALL SERVICES WILL BE AVAILABLE TO INDIVIDUALS REGARDLESS OF RACE, SEX, RELIGION, AGE, NATIONAL ORIGIN, COLOR, MARITAL STATUS, IMPAIRMENT OR POLITICAL BELIEF.
O. Vocational Rehabilitation Application Form
Department of Labor and Economic Growth
MICHIGAN COMMISSION FOR THE BLIND
CLIENT SERVICES DIVISION
STREET, CITY, STATE ZIP
PHONE
Client: FirstName LastName
Counselor:
APPLICATION FOR VOCATIONAL REHABILITATION SERVICES
In accordance with the 1998 Amendments to the Rehabilitation Act of 1973 and Public Act 260 of the State of Michigan, I am applying for vocational rehabilitation services.
ELIGIBILITY
I understand that in order to be eligible I must have a visual impairment as defined by the Michigan Commission for the Blind (MCB), the impairment must constitute or result in a significant impediment to employment and I must need vocational rehabilitation services in order to prepare for employment. It is presumed that I can benefit in terms of an employment outcome as a result of vocational rehabilitation services unless the MCB can demonstrate by clear and convincing evidence that I am not capable of an employment outcome. This determination of eligibility will, to the extent possible, be based on existing information and will be completed within 60 days, unless my counselor and I mutually agree that an extension is necessary due to exceptional and unforeseen circumstances beyond my control or the agency's control and I sign an agreement that an extension of time is warranted. The extension must be for a specific period of time.
If I am eligible, an Individual Plan for Employment (IPE) will be written with my direct participation. In the development of this plan I will be given comprehensive information in order to assist me in making appropriate choices of service with my counselor. My counselor and I will review this plan every 12 months to assess my progress towards my Employment Objective. I will be included in any decisions to change this plan. I will receive copies of information pertinent to my case in the media I have indicated, e.g., Braille, tape. large print, computer disk or regular print.
ORDER OF SELECTION
Under an order of selection, I will be classified based on the categories below. In the most severe category I may be eligible for all appropriate paid and non-paid services. In lower categories I may only be eligible for non-paid services which might include diagnostic service, counseling and guidance, referral and job placement. If I am found eligible for services I will be assigned to the highest possible category. My category may change should my circumstances change.
SELECTION CATEGORIES
1. Individuals with the most significant disabilities;
2. Individuals with significant disabilities;
3. Individuals with less significant disabilities;
4. Individuals with non-significant disabilities;
INELIGIBILITY
If my impairment is judged to be too severe to allow me to benefit from services at any time in the vocational rehabilitation process, I must be allowed to undergo an extended assessment, which may last up to 18 months before I may be determined ineligible. The basis for an ineligibility decision will be recorded in my record and will be certified by an appropriate staff person.
CONFLICT RESOLUTION AND RIGHTS
Most conflicts arise out of miscommunication. The following steps are to assists in the resolution of the conflict:
1. Administrative Review – A meeting between you and your counselor/teacher, his/her supervisor and an agency administrator for the purpose of resolving the conflict.
2. Mediation Services – A meeting between you and your counselor/teacher and his/her supervisor conducted by an impartial professional mediator.
3. Fair Hearing – A hearing before an Administrative Law Judge designed to settle conflicts. The Administrative Law Judge will render a ruling regarding your issues. If you are not satisfied with the decision of the Administrative Law Judge you may appeal this decision to the Director of the Department of Labor and Economic Growth. At no time will the above two forms of conflict resolution be used to delay the scheduling of a Fair Hearing, if you choose.
To request an Administrative Review contact the supervisor in the region at 1-800-292-4200. To arrange for Mediation Services or a Fair Hearing you may contact the Michigan Commission for the Blind Hearing Coordinator at 1-800-292-4200 or by making the request by phone or in writing to your Counselor/Teacher or the Hearing Coordinator. There is no cost to you for these activities. However, the agency will not pay the costs, if any, for an advocate or attorney.
You have the right to be represented by an advocate of your choosing at any time during the rehabilitation process or the conflict resolution activities mentioned above. You also have the right to obtain assistance through the Client Assistance Program (CAP) at any time. CAP may be reached at 1-800-292-5896.
ALL SERVICES WILL BE AVAILABLE TO ME REGARDLESS OF RACE, SEX, RELIGION, AGE, NATIONAL ORIGIN, COLOR, MARITAL STATUS, IMPAIRMENT OR POLITICAL BELIEF.
The above information has been discussed with me and I have received a copy in the media of my choice.
Client Signature: Date:
(or Designee)
P. Vocational Rehabilitation Authorization Form
Department of Labor and Economic Growth
MICHIGAN COMMISSION FOR THE BLIND
CLIENT SERVICES DIVISION
STREET, CITY, STATE ZIP
PHONE
SERVICE AUTHORIZATION
AUTHORIZATION #: Date Issued:
Budget Account*:
Client:
Vendor SSN*:
Vendor Name:
Pay to Number:
Address:
Description of Service*:
Service Dates: Thru
Serv. Type:
Unit Price:$ per Unit No. Units: Amt:$
Service detail:
Agency Object:
Void After:
Total amount authorized: $
Authorized Signature:
Authorizer's Name:
Please submit invoices to the authorizer at address above. Authorization is hereby given to provide the services described above. Payment can only be made for the services authorized and at the rates authorized. If there is any change required in this authorization the Vendor must contact the authorizer first. Payment will be made promptly upon receipt of properly prepared invoices.
Authority: P. A. 260 of 1978, as amended Index:
Completion: Mandatory PCA:
Penalty: Services may not be provided
Q. Closure Information – VR Form
DEPARTMENT OF LABOR & ECONOMIC GROWTH
MICHIGAN COMMISSION FOR THE BLIND
CLIENT SERVICES DIVISION
STREET
CITY, STATE ZIP
PHONE
CLOSURE INFORMATION - VR
Last: LastName First: FirstName MI: MI
Street:
City:
County*: Zip*:
Phone:
Birthdate:
VR Services Provided:
Assessment Services*
Funding Source *
Restoration*
Funding Source *
Counseling & Guidance*
Funding Source *
Job Finding*
Funding Source *
Transportation*
Funding Source *
Job Placement*
Funding Source *
On-The-Job Supports*
Funding Source *
Maintenance*
Funding Source*
Rehab Technology*
Funding Source*
Other Services*
Funding Source *
Technical Assistance Services (for self-employment, telecommuting, etc.)*
Funding Source *
Training Services
Disability Related Augmentative Skills*
Funding Source *
College/University*
Funding Source *
Business & Vocational*
Funding Source *
On-the-job*
Funding Source *
Miscellaneous*
Funding Source *
Basic Academic Remedial/Literacy Training*
Funding Source *
Job Readiness*
Funding Source *
Other Services
Reader Assistance*
Funding Source *
Interpreter Services*
Funding Source *
Attendant Services*
Funding Source *
Information and Referral Services*
Funding Source *
Public Support at Closure(Y=Yes N=No):
Received? Monthly
Amount
SSI Aged?
SSI Blind?
SSI Disabled?
Temporary Assistance for Needy Families (TANF)?
General Assistance (State or Local Government)?
Social Security Disability Insurance (SSDI)?
Veterans' Disability Benefits?
Workers' Compensation?
Other Public Support?
Honorably Discharged Veteran?
Migrant and Seasonal Farmworker*
Projects with Industry?
At Closure:
Level of Education Achieved at Closure*
Employment Status*
Previously Employed?
Year Last Employed:
Hours of Paid Work During Previous Week*:
Weekly Earnings at Closure:
Competitive Employment*:
Primary Source of Support*
Medical Insurance at Closure
Medicaid?
Medicare?
Public Insurance from Other Sources?
Private Medical Insurance through own Employer?
Private Medical Insurance through Other Means?
Status 26 Closure Information:
Occupation Code*
DOT:
Employer*
Information related to closure in other Statuses:
Reason for Closure*
Supported Employment Closure Information:
Long Term Funding Source*
Supported Employment Status*
Supported Employment Outcome Type*
Date Opened in Supported Employment:
R. IL Application Form
Department of Labor and Economic Growth
MICHIGAN COMMISSION FOR THE BLIND
CONSUMER SERVICES DIVISION
Client:
IL Specialist:
INDEPENDENT LIVING PROGRAM APPLICATION
By signature, I acknowledge that I understand my right to appeal which has been discussed with me, and my ability to seek further assistance from the Michigan Protection and Advocacy Service at 800-292-5896 if need be.
By signature, I acknowledge making application for services from the Commission for the Blind, Independent Living Program, and accept the responsibility to cooperate by making a reasonable effort on my own behalf and using all available resources in accordance with the guidelines set up by the Michigan Commission for the Blind.
By signature, I acknowledge that this application has been discussed with me and that I have provided answers to the IL Specialist to be used for program use only.
Client Signature:
Date:
S. IL Eligibility Form
DEPARTMENT OF LABOR AND
ECONOMIC GROWTH
MICHIGAN COMMISSION FOR THE BLIND
CLIENT SERVICES DIVISION
STREET
CITY, STATE ZIP
PHONE
IL ELIGIBILITY
Client:
55 years of age or older:
under 55 but multiply disabled:
Client Waived Plan? (Y/N):
By signature, the IL Specialist determines that the client is: 55 years of age or older or under age 55 but multiply disabled, and is severely visually impaired which makes competitive employment extremely difficult to attain, but for whom independent living goals are feasible.
IL Specialist: Date:
T. IL Objective and Needs form
DEPARTMENT OF LABOR AND
ECONOMIC GROWTH
MICHIGAN COMMISSION FOR THE BLIND
STREET, CITY, STATE, ZIP
PHONE
CONSUMER SERVICES DIVISION
IL Intermediate Objectives
Client:
Self-care: Increase client's self care skills to allow greater independence in the home or community.
Communication: Increase client's communication skills to allow greater independence in reading & writing.
Mobility: Increase client's mobility skills to allow greater independence traveling around the home and/or community.
Residential: Increase client's ability to live in a more independent living environment.
Educational: Increase client's basic knowledge of to allow greater independence in performing.
Vocational: Increase client's understanding of vocational options.
Other:
U. IL Open and Closure Information
DEPARTMENT OF LABOR AND
ECONOMIC GROWTH
MICHIGAN COMMISSION FOR THE BLIND
CLIENT SERVICES DIVISION
STREET
CITY, STATE ZIP
PHONE
IL OPEN & CLOSURE INFORMATION
Date Client Added:
Caseload Number: Office Number:
Courtesy Title: Last: First: M.I.:
Residential Address
Street: Zip*:
City: County*:
State:
Remarks:
Phone Number: Work Phone:
TDD (Y/N):
Mailing Address
Address: Zip*:
City: State:
DOB:
Race*:
Sex:
Hispanic (Y/N):
Living Arrangement*:
Referral Source*:
Referral Date:
Visual Disability*:
Non-Visual Disabilities (mark Y or N):
Alzheimer's Disease
Amputations
Arthritis
Cancer
Dementia (non-Alzheimer's)
Diabetes (Type I or II)
Epilepsy, CP, MS, etc.
Hearing Impaired
Heart Disease/Surgery
High Blood Pressure
Kidney Failure
Limb Fractures/Injuries
Mental Retardation
Neuropathies, e.g. Diabetic
Other
Other Mental Limitations
Respiratory/Lung Conditions
Stroke
V. IL Closure Form
DEPARTMENT OF LABOR AND
ECONOMIC GROWTH
MICHIGAN COMMISSION FOR THE BLIND
CLIENT SERVICES DIVISION
STREET
CITY, STATE ZIP
PHONE
IL CLOSURE REPORT
Client:
Relocated from Nursing Home? (Y/N):
IL Services Prevented Entry into Nursing Home? (Y/N):
Date Closed:
Reason for Closure*:
W. IL Service Authorization
DEPARTMENT OF LABOR AND
ECONOMIC GROWTH
MICHIGAN COMMISSION FOR THE BLIND
CLIENT SERVICES DIVISION
STREET
CITY, STATE ZIP
PHONE
IL OB SERVICE AUTHORIZATION
AUTHORIZATION #: Date Issued:
Budget Account*:
Client:
Vendor SSN*:
Vendor Name:
Pay to Number:
Address:
Description of Service*:
Service Dates: Thru
Serv. Type:
Unit Price:$ per Unit: No. Units: Amt:$
Service detail:
Agency Object:
Void After:
Total amount authorized: $
Authorized Signature:
Authorizer's Name:
Please Submit invoices to the authorizer and Address above. Authorization is hereby given to provide the services describe above. Payment can only be made for the services authorized and at the rates authorized. If there is any change required in this authorization the Vendor must contact the authorizer first. Payment will be made promptly upon receipt of properly prepared invoices.
Authority: P. A. 260 of 1978, as amended Index:
Completion: Mandatory PCA:
Penalty: Services may not be provided
X. Youth Low Vision Application
DEPARTMENT OF LABOR AND ECONOMIC GROWTH
MICHIGAN COMMISSION FOR THE BLIND
CONSUMER SERVICES DIVISION
125 E Union St 7th floor
Flint, MI 48502
(810)760-2030
YOUTH LOW VISION PROGRAM APPLICATION
Eligibility: Youth, age birth through 26 receiving Visually Impaired Services through the local school district may be eligible based upon one of the following criteria:
• Visual acuity of 20/70 or less in the best corrected eye
• Visual field restriction less than 20 degrees or less
AN EYE REPORT MUST BE INCLUDED WITH THIS APPLICATION.
Student’s name: ___________________________________________________
(Please Print
Date of birth:
______________________________________________________
Address:
__________________________________________________________
City, state, and zip code:
_____________________________________________
Telephone number, including area code: _______________________________
Vision/Medical Insurance: ___________________________________________
Low Vision Provider _____________________________________________
(*** List of approved providers available from Michigan Commission f/t Bind staff)
Teacher Consultant _____________________________Telephone___________
Parent/guardian signature
I am applying for Youth Low Vision services available from the Michigan Commission for the Blind (MCB) on behalf of my child. In signing this application, I also authorize MCB staff to share information with the referring school district and low vision practitioner as necessary to provide optimal services.
Signature:______________________________Date: _________
Print name _________________________________________
Services are available to students regardless of race, sex, religion, national origin, color, marital status, impairment or political belief.
Y. Youth Low Vision Service Authorization
DEPARTMENT OF LABOR AND
ECONOMIC GROWTH
MICHIGAN COMMISSION FOR THE BLIND
CLIENT SERVICES DIVISION
STREET
CITY, STATE ZIP
PHONE
YLV SERVICE AUTHORIZATION
AUTHORIZATION #: Date Issued:
Budget Account*:
Client:
Vendor SSN*:
Vendor Name:
Pay to Number:
Address:
Description of Service*:
Service Dates: Thru
Serv. Type:
Unit Price:$ per Unit: No. Units: Amt:$
Service detail:
Agency Object:
Void After:
Total amount authorized: $
Authorized Signature:
Authorizer's Name:
Phone: Fax:
Please Submit invoices to the authorizer and Address above. Authorization is hereby given to provide the services describe above. Payment can only be made for the services authorized and at the rates authorized. If there is any change required in this authorization the Vendor must contact the authorizer first. Payment will be made promptly upon receipt of properly prepared invoices.
Authority: P. A. 260 of 1978, as amended Index:
Completion: Mandatory PCA:
Penalty: Services may not be provided
Z. Youth Low Vision Evaluation form
LOW VISION EVALUATION
Dept. of Labor & Economic Growth
Michigan Commission for the Blind
Student Name:
Based upon the Low Vision Evaluation provide the following information:
A: HISTORY
1. History of onset of low vision (including, but not limited to onset, duration, etiology and any ocular surgery):
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________
2. Present spectacle correction:
OD:_________________________ Distance VA: ______
OS:_________________________ Distance VA: ______
ADD OD: _____________ Near VA: ____________
ADD OS: _____________ Near VA: ____________
3. Contact Lenses: (if worn)
Power OD: _________________ Type OD: __________
Power OD: _________________ Type OS: __________
4. Current Low Vision Devices: (list types, power, and visual acuities with
devices)
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________
5. Diagnosis (“X” appropriate terms):
__ Permanent:
__ Progressive:
Prognosis ("X" appropriate terms):
Patient's vision is considered -
Stable:
Deteriorating:
Capable of improvement:
Uncertain:
B. STUDENT GOALS
________________________________________________________________
________________________________________________________________
________________________________________________________________
C: SUMMARY OF FINDINGS
1. Final Refraction:
OD: _________________________ VA: ______________
OS: _________________________ VA: ______________
At near OD: __________ VA: _________
OS: __________ VA: _________
2. Nature and Extent of Visual Fields:
________________________________________________________________
________________________________
3. Near Devices: (Provide description of type, power and visual acuity of near
devices recommended)
___________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
_______
4. Telescopic Evaluation: (Provide type, power and acuity for each device
recommended)
________________________________________________________________
________________________________________________________________
________________________________________________________________
__________________________________________________________
5. Selective Absorption Filters: (Provide type and describe the benefit of use over more traditional glare methods)
________________________________________________________________
________________________________________________________________
______________________
D. RECOMMENDED TREATMENT
1. Description of Recommended Low Vision Aids: (Include manufacturer, power range and cost for each device)
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
____________________________________________________
Signature of Examiner ________________________________
Examiner (Print) __________________________ Date ______
DEPARTMENT OF LABOR AND ECONOMIC GROWTH
MICHIGAN COMMISSION FOR THE BLIND
CONFIDENTIALITY STATEMENT
This statement of confidentiality applies to all driver and readers with the Michigan Commission for the Blind.
I understand that all information and verbal or written that relates to any and all clients and staff of the Michigan Commission for the Blind is not to be discussed or shared with anyone under any circumstances. Failure to abide by these principles will result in dismissal.
SIGNATURE:
DATE:
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