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

OMB Control No. 2900-0092
Respondent Burden: 45 Minutes
Expiration Date: XX-XX-XXXX

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, and 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
http://www.reginfo.gov/public/do/PRAMain. 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 WORK PHONE NUMBER

3. CURRENT ADDRESS

6. MARITAL STATUS

5. GENDER
MALE

4b. E-MAIL ADDRESS 2

7. CLAIM NUMBER

8. SOCIAL SECURITY NUMBER

FEMALE

9. CLAIMING DEPENDENTS?

YES

4a. E-MAIL ADDRESS 1

NO

10. NICKNAME/AKA

11. EMERGENCY CONTACT INFORMATION
CONTACT NAME
CONTACT PHONE NUMBER

#:_____

CONTACT RELATIONSHIP

12. HOW DO YOU EXPECT THIS PROGRAM TO HELP YOU?

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

14. HAVE YOU EVER PARTICIPATED IN OR ARE CURRENTLY PARTICIPATING IN A VA EDUCATION BENEFIT PROGRAM?
YES

NO

14A. HAVE YOU EVER PARTICIPATED 14B. CHECK ALL THAT APPLY IN WHICH YOU HAVE PARTICIPATED
IN A PROGRAM OF VOCATIONAL
WORKER'S COMP
PRIVATE
REHABILITATION BEFORE?
STATE VOCATIONAL REHABILITATION
OTHER (Please explain)
NO
YES
VA VOCATIONAL REHABILITATION
(If "Yes," complete Items 14B and 14C)
14C. 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.
15. CIVILIAN EMPLOYMENT HISTORY: Please start with your most current position.
DATES
TO

AVERAGE GROSS
MONTHLY SALARY

STATUS
TEMPORARY ASSIGNMENT OR CONTRACT
PERMANENT POSITION

PART TIME
FULL TIME

DATES
TO

AVERAGE GROSS
MONTHLY SALARY

STATUS
TEMPORARY ASSIGNMENT OR CONTRACT
PERMANENT POSITION

PART TIME
FULL TIME

JOB TITLE

FROM
COMPANY NAME

A
DESCRIBE JOB DUTIES IN DETAIL
REASON FOR LEAVING
JOB TITLE

FROM

B

COMPANY NAME

VA FORM
FEB 2012

28-1902w

SUPERSEDES VA FORM 28-1902w, FEB 2010,
WHICH WILL NOT BE USED

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

B

REASON FOR LEAVING
DATES
TO

AVERAGE GROSS
MONTHLY SALARY

STATUS
TEMPORARY ASSIGNMENT OR CONTRACT
PERMANENT POSITION

PART TIME
FULL TIME

DATES
TO

AVERAGE GROSS
MONTHLY SALARY

STATUS
TEMPORARY ASSIGNMENT OR CONTRACT
PERMANENT POSITION

PART TIME
FULL TIME

JOB TITLE
FROM
COMPANY NAME

C
DESCRIBE JOB DUTIES IN DETAIL
REASON FOR LEAVING
JOB TITLE

FROM
COMPANY NAME

D
DESCRIBE JOB DUTIES IN DETAIL
REASON FOR LEAVING

16. 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.
HIGHEST RANK ACHIEVED:_____________
JOB TITLE

ARMED SERVICES:

ARMY

AIR FORCE

MARINES

COAST GUARD

AVERAGE GROSS
MONTHLY SALARY

DATES
TO

FROM

A

NAVY

LIST ANY HONORS AND COMMENDATIONS

RANK

DESCRIBE JOB DUTIES IN DETAIL

HIGHEST RANK ACHIEVED:_____________

ARMED SERVICES:

ARMY

JOB TITLE

AIR FORCE

DATES
TO

FROM

B

NAVY

LIST ANY HONORS AND COMMENDATIONS

MARINES
COAST GUARD
AVERAGE GROSS
MONTHLY SALARY
RANK

DESCRIBE JOB DUTIES IN DETAIL

HIGHEST RANK ACHIEVED:_____________

ARMED SERVICES:

JOB TITLE
FROM

C

LIST ANY HONORS AND COMMENDATIONS

ARMY

NAVY
DATES
TO

AIR FORCE

MARINES

COAST GUARD

AVERAGE GROSS
MONTHLY SALARY
RANK

DESCRIBE JOB DUTIES IN DETAIL

17. WOULD IT BE POSSIBLE FOR YOU TO RETURN TO WORK IN A FORMER OCCUPATION OR FOR A FORMER EMPLOYER?
YES

NO

VA FORM, 28-1902w, FEB 2012

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MILITARY WORK HISTORY (CONTINUED)

18. WHAT WORK SKILLS DID YOU USE IN YOUR PREVIOUS POSITIONS THAT YOU THINK YOU MAY BE ABLE TO USE IN A NEW JOB?

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

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.

20. MARK HIGHEST LEVEL COMPLETED:

SOME HS - HIGHEST GRADE COMPLETED:_____
MASTER

HS - YEAR______

GED - YEAR______

ASSOCIATE

BACHELOR

DOCTORAL

21A. NAME OF SCHOOL

21B. DATES (MM/YYYY)
FROM

TO

21C.
GPA

21D.
CREDITS/
CLOCK
HOURS

22A. WHAT SUBJECTS DID YOU LIKE?

21E. MAJOR COURSE
OF STUDY

21F. DEGREE (if any),
YEAR RECEIVED

22B. WHAT SUBJECTS DID YOU DISLIKE?

1
2
3

1
2
3

23A. DO YOU HAVE ANY CURRENT VOCATIONAL
CERTIFICATES AND/OR LICENSES?
YES

NO

(If "Yes," complete Items 23B and 23C)

23B. LIST CERTIFICATES/LICENSES

(Apprentices or journeyman card, truck driver/CDL, etc.)

23C. DATE
EXPIRES

1
2
3

24. HAVE YOU BEEN DIAGNOSED WITH A LEARNING DISABILITY? (If "Yes," please describe below):

DISABILITIES

List and describe your service-connected disability(ies). Please list the disability(ies) in order of severity.
25A. SERVICE-CONNECTED DISABILITY

25B. RATING
(%)

25C. WHAT DIFFICULTIES ARE YOU EXPERIENCING DUE TO YOUR
DISABILITIES?

26A. NON SERVICE-CONNECTED
DISABILITY

26B. RATING
(%)

26C. WHAT DIFFICULTIES ARE YOU EXPERIENCING DUE TO YOUR
DISABILITIES?

27. HAS YOUR SERVICE-CONNECTED DISABILITY(IES) AFFECTED YOU IN THE FOLLOWING AREAS OF WORK? (Check all that apply)
JOB PERFORMANCE
JOB SATISFACTION
VA FORM, 28-1902w, FEB 2012

JOB OPPORTUNITIES
MISSED WORK TIME

CO-WORKER RELATIONS
MANAGER RELATIONS

OTHER (Please explain)

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DISABILITIES (CONTINUED)
28. ARE ANY OF YOUR DISABILITIES IMPROVING? 29. ARE YOUR DISABILITIES STABLE?
YES
NO
YES
NO

30. ARE ANY OF YOUR DISABILITIES WORSENING?
YES
NO

31. DO YOU RECEIVE ANY OF THE FOLLOWING? (Check all that apply)
RETIREMENT (Military/civilian)

WORKERS COMPENSATION BENEFITS

WELFARE ASSISTANCE

DISABILITY PENSION (Military/civilian)

SOCIAL SECURITY DISABILITY INCOME (SSDI/SSI)

MEDICARE/MEDICAID

UNEMPLOYMENT

ALIMONY/CHILD SUPPORT

OTHER______________________

32. DO YOU HAVE A CLAIM PENDING FOR ANY OF THE FOLLOWING? (Check all that apply)
RETIREMENT (Military/civilian)

WORKERS COMPENSATION BENEFITS

WELFARE ASSISTANCE

DISABILITY PENSION (Military/civilian)

SOCIAL SECURITY DISABILITY INCOME (SSDI/SSI)

MEDICARE/MEDICAID

UNEMPLOYMENT

ALIMONY/CHILD SUPPORT

OTHER______________________

MEDICAL TREATMENT

Please describe medical treatment you have received or are receiving.
33B. NAME OF VA OR PRIVATE
MEDICAL FACILITY

33A. CONDITION

34A. DO YOU HAVE MEDICAL NEEDS
THAT ARE NOT BEING MET?
YES

33C. HOW OFTEN SEEN
FOR TREATMENT

33D. MEDICATION(S) PRESCRIBED

34B. WHAT DO YOU NEED?

NO

(If "Yes," complete Item 34B)
35A. DO YOU USE ANY ADAPTIVE
EQUIPMENT SUCH AS BRACES,
ARTIFICIAL LIMBS, HEARING AIDS,
ETC?
YES
NO

35B. PLEASE DESCRIBE YOUR ADAPTIVE EQUIPMENT

(If "Yes," complete Item 35B)
36A. ARE THERE OTHER PROBLEMS
OR ISSUES WITH WHICH YOU
WOULD LIKE HELP?
YES

36B. PLEASE LIST OTHER PROBLEMS OR ISSUES WITH WHICH YOU WOULD LIKE HELP

NO

(If "Yes," complete Item 36B)
37. DO YOU HAVE ANY PENDING VA CLAIMS?
YES
NO (If "Yes," please describe below)

38. DO YOU NEED INFORMATION ABOUT OTHER VA BENEFITS OR PROGRAMS?
YES
NO (If "Yes," please describe below)

MISCELLANEOUS

The following information will be used for employment planning purposes.

39A. DO YOU: 39B. DO YOU HAVE STABLE
HOUSING AT PRESENT?
RENT
OWN

YES

39C. DESCRIBE YOUR CURRENT LIVING SITUATION:

NO

(If "No," complete Iten 39C)

OTHER
40A. WHAT MODE OF TRANSPORTATION DO YOU USE?
40B. HOW FAR ARE YOU WILLING TO COMMUTE
FOR WORK AND/OR SCHOOL?

PERSONAL

PUBLIC TRANSPORTATION

40C. DO YOU HAVE A VALID DRIVER'S LICENSE?
YES

VA FORM, 28-1902w, FEB 2012

OTHER

NO
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MISCELLANEOUS (CONTINUED)

41. ARE YOU WILLING TO RELOCATE FOR A JOB?
YES

NO

42. IF YOU HAVE HAD A HISTORY OF OR ARE CURRENTLY DEALING WITH LEGAL ISSUES, PLEASE SELECT AND DESCRIBE BELOW:
BANKRUPTCY

MISDEMEANOR

FELONY

PROBATION

PAROLE

OTHER

N/A

43. IF YOU HAVE HAD AND/OR PRESENTLY HAVE SUBSTANCE ABUSE ISSUES, PLEASE SELECT AND DESCRIBE BELOW:
DRUGS (Illicit)
DRUGS (Prescription)
ALCOHOL
OTHER

44. IF YOU HAVE A HISTORY OF OR ARE CURRENTLY IN ON-GOING TREATMENT(S) FOR SUBSTANCE ABUSE(S), PLEASE DESCRIBE BELOW:

45. DID ANYONE HELP YOU COMPLETE THIS FORM?
YES

DATE COMPLETED

NO

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 Title 38, United States Code, 1.576, Veterans Benefits. This information is needed to
assist in vocational and educational planning, to authorize my receipt of rehabilitation services, to develop a
record of my vocational progress, and to assure I obtain the best results from my 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 of 1974, including the routine
uses identified in VA system of records, 58VA21/22/28, Compensation, Pension, Education, and Vocational
Rehabilitation and Employment Records-VA, published in the Federal Register. Generally, disclosures under the
authority of a routine use will be made to develop my claim for 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

DATE SIGNED

SIGNATURE OF CASE MANAGER OR VOCATIONAL REHABILITATION COUNSELOR (VRC)

DATE SIGNED

VA FORM, 28-1902w, FEB 2012

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