VA Form 28-10289 Monthly Progress Report-Veteran Readiness and Employment

OMB 2900-NEW
Respondent Burden: 15 Minutes
Expiration Date: XXXXXXXX

VA DATE STAMP
(DO NOT WRITE IN THIS SPACE)

MONTHLY PROGRESS REPORT VETERAN READINESS AND EMPLOYMENT

INSTRUCTIONS: Before completing this form, read the Privacy Act and Respondent Burden on Page 4. Use this form
to submit Veteran Employment activity progress (i.e., job referrals, workshops, interviews, etc.) For more information,
you can contact us online through Ask VA: https://ask.va.gov/. Ask us a question online or call us toll-free at
1-800-827-1000 (TTY: 711). VA forms are available at www.va.gov/vaforms. After completing the form, electronically
email it to the assigned Veteran Readiness & Employment Case Manager or mail to: Department of Veterans Affairs,
Evidence Intake Center, P.O. Box 4444, Janesville, WI, 53547-4444.

SECTION I: VETERAN'S IDENTIFICATION INFORMATION
NOTE: You may complete the form online or by hand. If completed by hand, print the information requested in ink, neatly and legibly, insert one letter per box, and
completely fill in each applicable check circles to help expedite processing of the form.
1. VETERAN'S NAME (First, Middle Initial, Last)

3. TODAY'S DATE (MM/DD/YYYY)

2. STATE IDENTIFICATION NUMBER

Month

Year

Day

4. MAILING ADDRESS (If applicable) (Number and Street or Rural Route, P.O. Box, City, State, ZIP Code and Country)
No. &
Street
Apt./Unit Number

City

State/Province

Country

ZIP Code/Postal Code

5. TELEPHONE NUMBER (Include Area Code)
Enter International Phone Number (If applicable)
6. EMAIL ADDRESS (Optional)

7. EMPLOYMENT GOAL

8. REFERRAL DATE (MM/DD/YYYY)
Month

Day

9. DATE OF LAST CONTACT (MM/DD/YYYY)
Year

Month

Day

Year

10. STATE WORKFORCE CASE MANAGER'S NAME AND TITLE

SECTION II: MONTHLY INFORMATION REQUIRED
Indicate the job search efforts of the VR&E Participant and DVOP/AJC Case Manager during this reporting period.
11. JOB SEARCH EFFORTS:
11A. HAS THE PARTICIPANT DEVELOPED A TARGETED RESUME THIS MONTH?

YES

NO

11B. HAS THE PARTICIPANT PARTICIPATED IN AN INTERVIEW THIS MONTH?

YES

NO
YES

11C. HAS THE PARTICIPANT ATTENDED A CAREER SEARCH PREPARATION WORKSHOP THIS MONTH?
YES

11D. HAS THE PARTICIPANT ATTENDED A CAREER FAIRS/HIRING EVENTS THIS MONTH?
YES

11E. HAS THE PARTICIPANT APPLIED FOR CAREER OPPORTUNITIES THIS MONTH?
11F. HAS THE PARTICIPANT ACCEPTED AN EMPLOYMENT OFFER THIS MONTH?
11G. HAS THE PARTICIPANT BEEN COOPERATIVE/RESPONSIVE THIS MONTH?

VA FORM
XXX XXXX

28-10289

YES
YES

NO

NO
NO

NO
NO

Page 1

SECTION III: SUMMARY REPORT
New Employment Information
Please provide VR&E Participant's Employment Information
12. START DATE (MM/DD/YYYY)

13. JOB TITLE

14. NAME OF EMPLOYER
15. EMPLOYER ADDRESS

16. HOURS PER WEEK

17. SALARY

18. POSITION TYPE
PERMANENT

19. WORK TYPE
TEMPORARY

FULL-TIME

PART-TIME

20. BENEFITS
MEDICAL

VACATION/TIME OFF

401K

LIFE INSURANCE

EDUCATION

21. NAME OF SUPERVISOR
22. TELEPHONE NUMBER (Include Area Code)
Enter International Phone Number (If applicable)

SECTION IV: VETERAN READINESS AND EMPLOYMENT (VR&E)
VETERANS' EMPLOYMENT AND TRAINING SERVICE (VETS)
JOB REFERRALS
23. DATE REFERRED

(MM/DD/YYYY)

24. JOB TITLE

25. EMPLOYER

26. APPLIED/
STATUS
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO

VA FORM 28-10289, XXX XXXX

Page 2

SECTION V: VR&E PARTICIPANT'S JOB SEARCH EFFORTS
NOTE: For submission of additional information, use a separate form (VA Form 28-10289) for each statement.
27. VR&E PARTICIPANT'S JOB SEARCH EFFORTS

VA FORM 28-10289, XXX XXXX

Page 3

SECTION VI: DVOP/AJC CASE MANAGER'S JOB SEARCH ASSISTANCE:
INDIVIDUALIZED CAREER SERVICES; REFERRALS FOR SUPPORTIVE SERVICES; LIVER SUPPORT
28. DVOP/AJC CASE MANAGER'S JOB SEARCH ASSISTANCE

SECTION VII: ADDITIONAL INFORMATION
29. REMARKS

SECTION VIII: AUTHORIZED SIGNATURE
30. CASE MANAGER SIGNATURE (REQUIRED)

31. DATE SIGNED (MM/DD/YYYY)

PENALTY: The law provides severe penalties (including fine and/or imprisonment) for willfully submitting any statement or evidence of a material fact you know to
be false, or for fraudulent receipt of any document you are not entitled to.
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., civil or criminal law enforcement, congressional communications, epidemiological or research studies, the collection of money owed to the
United States, litigation in which the United States is a party or has an interest, the administration of VA programs and delivery of VA benefits, verification of identity and status, and personnel
administration) as identified in the VA system of records, 58VA21/22/28, Compensation, Pension, Education, and Veteran Readiness and Employment Records - VA, published in the Federal
Register. Your obligation to respond is voluntary.
RESPONDENT BURDEN: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control
number. The OMB control number for this project is 2900-XXXX, and it expires XX/XX/20XX. Public reporting burden for this collection of information is estimated to average 15 minutes
per respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection
of information. Send comments regarding this burden estimate and any other aspect of this collection of information, including suggestions for reducing the burden, to VA Reports Clearance
Officer at VACOPaperworkReduAct@va.gov. Please refer to OMB Control No. 2900-XXXX in any correspondence. Do not send your completed VA Form 28-10289 to this email address.

VA FORM 28-10289, XXX XXXX

Page 4