Form VA Form 28-1902w VA Form 28-1902w Rehabilitation Needs Inventory

OMB Control No. 2900-0092
Respondent Burden: 45 Minutes

REHABILITATION NEEDS INVENTORY (RNI)
Privacy Act Notice: VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title
38, Code of Federal Regulations 1.576 for routine uses (i.e., to determine entitlement to vocational rehabilitation benefits and to plan a program of rehabilitation
services) as identified in the VA system of records, 58VA21/22/28, Compensation, Pension, Education, Vocational Rehabilitation and Employment Records - VA,
published in the Federal Register. Your obligation to respond is voluntary. Giving us your SSN account information is voluntary. Refusal to provide your SSN by itself
will not result in the denial of benefits. VA will not deny an individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by a
Federal Statute of law in effect prior to January 1, 1975, and still in effect. Information submitted is subject to verification through computer matching programs with
other agencies.
Respondent Burden: We need this information for educational and vocational planning to help you make the best use of your vocational rehabilitation benefits. Title 38,
United States Code chapter 31, allows us to ask for this information. We estimate that you will need an average of 45 minutes to review the instructions, find the
information, and complete this form. VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. You are not required
to respond to a collection of information if this number is not displayed. Valid OMB control numbers can be located on the OMB Internet Page at
www.whitehouse.gov/library/omb/OMBINV.VA.EPA.html#VA. If desired, you can call 1-800-827-1000 to get information on where to send comments or
suggestions about this form.
1. NAME (First, middle, last)
2. TELEPHONE NUMBER(S)
HOME PHONE NUMBER

CELL PHONE NUMBER

3. IF YOUR ADDRESS HAS CHANGED, GIVE YOUR NEW ADDRESS
4. E-MAIL ADDRESS
5. CLAIM NUMBER
7A. DID ANYONE ENCOURAGE YOU
7B. CHECK ALL THAT APPLY WHO ENCOURAGED YOU
TO APPLY FOR VOCATIONAL
VA REPRESENTATIVE
FAMILY MEMBER
REHABILITATION?
YES
NO
SERVICE ORGANIZATION
FRIEND
(If "Yes," complete Item 7B)
TRAINING FACILITY
STATE VOCATIONAL REHABILITATION
8. HOW DO YOU EXPECT THIS PROGRAM TO HELP YOU?

6. SOCIAL SECURITY NUMBER

OTHER (Please explain)

9. WHAT ARE THE JOBS OR CAREER FIELDS YOU ARE MOST INTERESTED IN?

10A. HAVE YOU EVER PARTICIPATED 10B. CHECK ALL THAT APPLY IN WHICH YOU HAVE PARTICIPATED
IN A PROGRAM OF VOCATIONAL
WORKER’S COMP
PRIVATE
REHABILITATION BEFORE?
YES
NO
STATE VOCATIONAL REHABILITATION
OTHER (Please explain)
(If "Yes," complete Items 10B and 10C)

VA VOCATIONAL REHABILITATION

10C. LIST ANY TYPE OF SERVICES YOU WERE PROVIDED (i.e., training, medical, vocational testing, functional capacities, job search activities)

EMPLOYMENT
Please fill out each area as completely as possible. If you have a resume, please attach it.

11. CIVILIAN EMPLOYMENT HISTORY: Please start with your most current position.
JOB TITLE
FROM
COMPANY NAME

A

DATES
TO

AVERAGE MONTHLY
SALARY

STATUS
TEMPORARY ASSIGNMENT OR CONTRACT

PART TIME

PERMANENT POSITION

FULL TIME

DESCRIBE JOB DUTIES IN DETAIL
REASON FOR LEAVING
JOB TITLE
FROM

DATES
TO

AVERAGE MONTHLY
SALARY

B
COMPANY NAME

VA FORM
FEB 2010

28-1902w

STATUS
TEMPORARY ASSIGNMENT OR CONTRACT
PERMANENT POSITION
Existing stock of VA Form 28-1902w, JUL 2007,
which will not be used.

PART TIME
FULL TIME

11. CIVILIAN EMPLOYMENT HISTORY (CONTINUED)
DESCRIBE JOB DUTIES IN DETAIL

B REASON FOR LEAVING
JOB TITLE
FROM
COMPANY NAME

C

DATES
TO

AVERAGE MONTHLY
SALARY

STATUS
TEMPORARY ASSIGNMENT OR CONTRACT

PART TIME

PERMANENT POSITION

FULL TIME

DESCRIBE JOB DUTIES IN DETAIL
REASON FOR LEAVING
JOB TITLE
FROM
COMPANY NAME

D

DATES
TO

STATUS
TEMPORARY ASSIGNMENT OR CONTRACT
PERMANENT POSITION

AVERAGE MONTHLY
SALARY

PART TIME
FULL TIME

DESCRIBE JOB DUTIES IN DETAIL
REASON FOR LEAVING

12. MILITARY WORK HISTORY: What did you do in the military? Please fill out the following area as completely as
possible. Please start with your last assignment.
JOB TITLE
FROM

DATES
TO

A MILITARY BRANCH

AVERAGE MONTHLY
SALARY

RANK

DESCRIBE JOB DUTIES IN DETAIL

JOB TITLE
FROM

DATES
TO

B MILITARY BRANCH

AVERAGE MONTHLY
SALARY

RANK

DESCRIBE JOB DUTIES IN DETAIL

JOB TITLE
FROM

DATES
TO

C MILITARY BRANCH

AVERAGE MONTHLY
SALARY

RANK

DESCRIBE JOB DUTIES IN DETAIL

JOB TITLE
FROM

D

MILITARY BRANCH
DESCRIBE JOB DUTIES IN DETAIL

DATES
TO

AVERAGE MONTHLY
SALARY

RANK

13. PLEASE EXPLAIN WHAT YOU DID DURING PERIODS OF UNEMPLOYMENT 3 MONTHS OR LONGER

14. WOULD IT BE POSSIBLE FOR YOU TO RETURN TO WORK IN A FORMER OCCUPATION OR FOR A FORMER EMPLOYER?
YES
NO
15. WHAT WORK SKILLS DID YOU USE IN YOUR PREVIOUS POSITIONS THAT YOU THINK YOU MAY BE ABLE TO USE IN A NEW JOB?

EDUCATION AND TRAINING
Please fill out the area below regarding your education/training background as completely as possible. Please include vocational,
college, on-the-job, and other training NOTE: Please include civilian and military schools/training.
16A. WHAT YEAR DID YOU GRADUATE HIGH SCHOOL?

16B. IF YOU DID NOT FINISH HIGH SCHOOL, DO YOU POSSESS A GED?
YES
17B. DATES

17A. NAME OF SCHOOL
FROM

NO
17C. MAJOR COURSE
OF STUDY

17D.
GPA

TO

18A. WHAT SUBJECTS DID YOU LIKE?

17E.
CREDITS/
CLOCK
HOURS

18B. WHAT SUBJECTS DID YOU DISLIKE?

1
2
3
4
5

1
2
3
4
5

19A. DO YOU HAVE ANY CURRENT VOCATIONAL
CERTIFICATES AND/OR LICENSES?
YES

NO

19B. LIST CERTIFICATES/LICENSES
(Apprentice or journeyman card, truck driver, etc.)

19C. DATE EXPIRES

1
2
3

(If "Yes," complete Items 19B and 19C)

DISABILITIES
List and describe your service-connected disability(ies). Please list the disability(ies) in order of severity.
20A. SERVICE-CONNECTED DISABILITY

20B. RATING (%)

20C. WHAT CAN’T YOU DO NOW BECAUSE OF THE DISABILITY CONDITION?

21A. NON SERVICE-CONNECTED DISABILITY

21B. RATING
(%)

21C. WHAT CAN’T YOU DO NOW BECAUSE OF THE DISABILITY CONDITION?

22. HAS YOUR SERVICE-CONNECTED DISABILITY(IES) AFFECTED YOU IN THE FOLLOWING AREAS OF WORK? (Check all that apply)
JOB PERFORMANCE
JOB SATISFACTION
VA FORM
FEB 2010

28-1902w

JOB OPPORTUNITIES
MISSED WORK TIME

CO-WORKER RELATIONS
MANAGER RELATIONS

23. HOW DO YOU FEEL ABOUT YOUR DISABILITY AND IT’S LIMITATIONS?

24. DO YOU RECEIVE ANY OR ALL OF THE FOLLOWING? (Check all that apply)
SOCIAL SECURITY DISABILITY INCOME (SSDI)

WORKERS COMPENSATION BENEFITS

WELFARE ASSISTANCE

PENSION BENEFITS
FOOD STAMPS
25. DO YOU HAVE A CLAIM PENDING FOR DISABILITY BENEFITS AND/OR OTHER BENEFITS, WITH ANY OF THE AGENCIES LISTED IN
ITEM 24?
YES
NO
26. ARE ANY OF YOUR DISABILITIES IMPROVING?
YES
NO
27. ARE YOUR DISABILITIES STABLE?
YES
NO
28. ARE ANY OF YOUR DISABILITIES WORSENING?
YES
NO
29. PLEASE EXPLAIN THE DIFFICULTIES YOU ARE EXPERIENCING NOW WITH ANY OF YOUR DISABILITIES

MEDICAL TREATMENT
Please describe medical treatment you have received or are receiving.
30A. CONDITION

30B. NAME OF VA OR PRIVATE
MEDICAL FACILITY

31A. DO YOU HAVE MEDICAL
NEEDS THAT ARE NOT BEING
MET?
YES
NO
(If "Yes," complete Item 31B)
32A. DO YOU USE ANY ADAPTIVE
EQUIPMENT SUCH AS BRACES,
ARTIFICIAL LIMBS, HEARING
AIDS, ETC?
YES

30D. MEDICATION(S) PRESCRIBED

31B. WHAT DO YOU NEED?

32B. PLEASE DESCRIBE YOUR ADAPTIVE EQUIPMENT.

NO

(If "Yes," complete Item 32B)
33A. ARE THERE OTHER PROBLEMS
OR ISSUES WITH WHICH YOU
WOULD LIKE HELP (e.g.,
childcare, financial difficulties,etc.)?
YES

30C. HOW OFTEN SEEN
FOR TREATMENT

33B. PLEASE LIST OTHER PROBLEMS OR ISSUES WITH WHICH YOU WOULD LIKE HELP.

NO

(If "Yes," complete Item 33B)
34. DID ANYONE HELP YOU COMPLETE THIS FORM?
YES
NO
35. DO YOU NEED INFORMATION ABOUT OTHER VA BENEFITS OR PROGRAMS?
YES
NO
36A. SIGNATURE OF VETERAN

37A. SIGNATURE OF CASE MANAGER

36B. DATE COMPLETED

37B. DATE REVIEWED
WITH VETERAN

PROTECTION OF PRIVACY INFORMATION STATEMENT
(For use by counselees and rehabilitation program participants)

I have been informed and understand that the information requested in this and any later interviews is
requested under the authorization of Section 210(c)(1) of title 38, United States Code, Veterans Benefits.
This information is needed to assist in vocational and educational planning, to authorize my receipt of
education benefits or rehabilitation services, to develop a record of my educational or vocational
progress, and to assure I obtain the best results from my education or rehabilitation program. I understand
that the information I provide will not be used for any other purpose and that my responses may be
disclosed outside the VA only if the disclosure is authorized under the Privacy Act, including the routine
uses identified in VA system of records, 58VA21/22/28, Compensation, Pension, Education, Vocational
Rehabilitation and Employment Records - published in the Federal Register. Generally, disclosures under
the authority of a routine use will be made to develop my claim for education or vocational rehabilitation
benefits under title 38, United States Code.
My giving the requested information is voluntary. I understand that the following results might occur if I
do not give this information:
(1) I may not receive the maximum benefit either from counseling or from my education or
rehabilitation program.
(2) If certain information is required before I may enter a VA program, my failure to give the
information may result in my not receiving the education or rehabilitation benefit for which I have
applied.
(3) If I am in a program in which information on my progress is required, my failure to give this
information may result in my not receiving further benefits or services.
My failure to give this information will not have a negative effect on any other benefit to which I may be
entitled.
I HEREBY CERTIFY THAT the information I have given above is true and correct to the best of my
knowledge and belief.

SIGNATURE OF VETERAN

VA FORM
FEB 2010

28-1902w

DATE SIGNED