Eligibility Worksheet

Should You Apply for DVR Services?

Are you thinking of applying for DVR services? This page will help you decide whether DVR can help you. As you proceed through this worksheet you will have an opportunity, if you choose, to apply for services.

Click here to return to the DVR home page and learn more about the kinds of services DVR provides.

To receive services from DVR you need to have a disability which is severe enough that you have problems getting or keeping a job specifically because of your disability.

Click here to see a list of common disabilities.

DVR does not have funding to work with everybody with a disability. We need to know how severe your problems are to know if we can serve you. You will be asked a series of questions about problems some disabilities cause for people. If you have found a way to deal with a potential problem by getting assistance from a family member or a neighbor or somebody else in your community, for purposes of this worksheet answer yes that you have that problem.

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Yes  No	Does your disability make it difficult for you to get to and from places, (especially to and from work)?  For example:
	Do you need assistance in walking? Does your disability make it difficult for you to drive or limit your driving? Do you need assistance leaving your home? Do you need assistance following directions or a map? Do you need assistance getting into stores or public buildings? Does your disability make it difficult for you to use public transportation?

Yes  No

Does your disability make it difficult for you to communicate (in the way you need to communicate at work)?  For example:

Do others need assistance to understand what you are saying? Do you need assistance to hear or understand what others are saying to you? Do you need assistance using the phone (or do you use a TTY, phone amplifier, or relay messages through others)? Do you need assistance either writing or reading text (or do you use Braille or speech synthesis)? Do you have difficulty explaining to others what you need?

Yes  No

Does your disability make it difficult for you to get ready to go to work, or to take care of yourself while you are working?  For example:

Do you need assistance getting dressed for work? Do you need assistance with bathing or grooming to go to work? Do you need assistance preparing food or eating? Do you need assistance toileting? Do you need assistance with handling money (for example, making change, knowing how to use vending machines, knowing how to budget your paycheck and pay bills, etc.)? Do you sometimes refuse or forget to take your medications? Have you attempted suicide? Do you have a guardian or legal payee? Are you under a commitment order?

Yes  No	Does your disability make it difficult for you to make realistic decisions or plans? Does your disability make it difficult for you to follow through with your plans? (This is sometimes the result of emotional problems, depression, or other mental illnesses.)

Yes  No	Does your disability make it difficult for you to get along with others at work?  For example:
	Do you have difficulty controlling your emotions (outbursts of anger, crying, laughing, giggling)? Do you usually have problems getting along with supervisors, teachers, or others in authority? Have you been asked to leave a store or office because of how you acted? Do you feel lonely or unable to fit in at work? Do your co-workers pick on you or make fun of you?

Yes  No	Does your disability make it difficult for you to work full-time or perform all the physical duties of most jobs?
Yes  No	Has your disability caused you to have a poor work record?
Yes  No	Has your disability made it difficult for you to learn new job skills?
Yes  No	Have you lost a job because you became disabled or were injured?

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Examples of Disabilities

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This is not an exhaustive list. There are many other types of disabilities other than those listed below.   The purpose of this list is to provide examples only.

AIDS/HIV	Hemophilia
Alcohol or Other Drug Disorder	Hip/Knee/Other Joint Dysfunction
Amputation	Kidney Failure
Arthritis	Mental Illness
Attention Deficit Disorder	Mental Retardation
Autism	Missing or Deformed Limb
Back Injury	Multiple Sclerosis
Blindness or Visual Impairment	Muscular Dystrophy
Brain Injury	Myofascial Disorder
Cancer	Paraplegia or Quadriplegic
Carpal Tunnel(Repetitive Use Syndrome)	Post Traumatic Stress Disorder
Cerebral Palsy(CP)	Respiratory/Pulmonary/Allergies
Cystic Fibrosis	Severe Arthritis
Deaf or Hard of Hearing	Specific Learning Disability
Depression	Spinal Cord Injury
Diabetes	Stroke
Epilepsy	Other
Fibromyalgia	Unknown
Heart Disease

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