Form 28-1902w Information for Veteran Readiness and Employment Entitle

OMB Approved No. 2900-0092
Respondent Burden: 45 Minutes
Expiration Date: XX/XX/20XX

INFORMATION FOR VETERAN READINESS AND
EMPLOYMENT ENTITLEMENT DETERMINATION
INSTRUCTIONS: Before the Vocational Rehabilitation Counselor (VRC) completes this form, read the Privacy Act and Respondent Burden to the claimant on page 9.
This form is used during the comprehensive initial evaluation to assist with gathering information for an Entitlement Determination. For more information, contact us at
https://ask.va.gov or call us toll-free at 1-800-827-1000. If you use a Telecommunications Device for the Deaf (TDD), the Federal relay number is 711. VA forms are available
at www.va.gov/vaforms.
During the claimant's initial evaluation, the VRC must complete the data fields indicated below. The VRC must use their counseling skills while utilizing this form to assist
with making an entitlement determination. The VRC will gather the responses from the claimant during the initial evaluation to address:
• Development and analysis of information necessary to obtain a general understanding of the whole individual.
• Evaluation of claimant's capacity for suitable employment and/or independence in daily living, in accordance with 38 CFR § 21.50.
• Entitlement determination to VR&E Program, including Employment Handicap (EH) and Serious Handicap (SEH) determination, in accordance with 38 CFR § 21.52.
• Develop and assess the following factors as part of the initial evaluation:
(1) Determination of the effect(s) of claimant's Service-Connected Disabilities (SCD) and Non-Service-Connected Disabilities (NSCD) condition(s) on obtaining
and maintaining employment, and on independence in daily living;
(2) The claimant's physical and mental capabilities that my affect employability and ability to function independently in daily living activities in family and
community;
(3) The claimant's abilities, aptitudes, and interests;
(4) The claimant's personal history and current circumstances (including educational and training achievements, employment record, developmental and related
vocationally significant factors, and family and community adjustment); and
(5) Other factors that may affect the claimant's employability.
• Identification of barriers that impact claimant's employability.
NOTE: If a positive entitlement determination has been made, information gathered on this form can be used to complete VA Form 28-1902f, Feasibility Determination
Narrative Report.

CLAIMANT'S INFORMATION
CLAIMANT'S NAME (First, Middle Initial, Last)

VA FILE NUMBER (Last four)

VRC NAME

SECTION I: VERIFICATION OF CLAIMANT'S CONTACT INFORMATION
1. CLAIMANT'S ADDRESS (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

2. CLAIMANT'S PHONE NUMBER (Include Area Code)
Enter International Phone Number (If applicable)
3. CLAIMANT'S EMAIL ADDRESS

4. GENDER
MALE

5. MARITAL STATUS
FEMALE

NON BINARY/THIRD GENDER

MARRIED

DIVORCED

SEPARATED

WIDOWED

NEVER MARRIED

6. CLAIMANT'S ASSIGNED POWER OF ATTORNEY

VA FORM
XXX 20XX

28-1902w

SUPERSEDES VA FORM 28-1902w, JUL 2024,
WHICH WILL NOT BE USED

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SECTION II: REVIEW OF CLAIMANT'S CIVILIAN EMPLOYMENT HISTORY

(If the claimant provides their resume, it is not necessary to duplicate information in Items 10-14. However, the civilian employment
(including self-employment) history must still be discussed to identify any difficulties with job duties, obtaining and maintaining
employment, salary, full time, part-time, and reasons why claimant left job positions).
CLAIMANT PROVIDED RESUME (Please complete fields not on resume)
7. IS THE CLAIMANT CURRENTLY EMPLOYED INCLUDING SELF EMPLOYMENT?

CLAIMANT DID NOT PROVIDE RESUME (Please complete the section below)
YES (If "Yes," go to #10)

NO (If "No," go to #8)

8. IF THE CLAIMANT IS UNEMPLOYED, HOW LONG HAS THE CLAIMANT BEEN UNEMPLOYED?
9. WHAT DID THE CLAIMANT DO DURING THE PERIOD OF UNEMPLOYMENT?

10. JOB TITLE:
NAME OF EMPLOYER:
DATES OF EMPLOYEMENT
FULL-TIME

PART-TIME

AVERAGE GROSS MONTHLY SALARY:

PROVIDE A DESCRIPTION OF JOB DUTIES IN DETAIL:

DO THE JOB DUTIES AGGRAVATE THE CLAIMANT'S SERVICE-CONNECTED DISABILITIES? (If "Yes," how?)

WHAT IS THE CLAIMANT'S REASON FOR LEAVING EMPLOYMENT? (e.g. resigned, fired, hired for another job)

11. JOB TITLE:
NAME OF EMPLOYER:
DATES OF EMPLOYEMENT
FULL-TIME
PART-TIME
AVERAGE GROSS MONTHLY SALARY:
PROVIDE A DESCRIPTION OF JOB DUTIES IN DETAIL:

DO THE JOB DUTIES AGGRAVATE THE CLAIMANT'S SERVICE-CONNECTED DISABILITIES? (If "Yes," how?)

WHAT IS THE CLAIMANT'S REASON FOR LEAVING EMPLOYMENT? (e.g. resigned, fired, hired for another job)

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SECTION II: REVIEW OF CLAIMANT'S CIVILIAN EMPLOYMENT HISTORY (Continued)
(If the claimant provides their resume, it is not necessary to duplicate information in Items 10-14. However, the civilian employment
(including self-employment) history must still be discussed to identify any difficulties with job duties, obtaining and maintaining
employment, salary, full time, part-time, and reasons why claimant left job positions).
12. JOB TITLE:
NAME OF EMPLOYER:
DATES OF EMPLOYEMENT
FULL-TIME
PART-TIME
AVERAGE GROSS MONTHLY SALARY:
PROVIDE A DESCRIPTION OF JOB DUTIES IN DETAIL:

DO THE JOB DUTIES AGGRAVATE THE CLAIMANT'S SERVICE-CONNECTED DISABILITIES? (If "Yes," how?)

WHAT IS THE CLAIMANT'S REASON FOR LEAVING EMPLOYMENT? (e.g. resigned, fired, hired for another job)

13. JOB TITLE:
NAME OF EMPLOYER:
DATES OF EMPLOYEMENT
FULL-TIME
PART-TIME
AVERAGE GROSS MONTHLY SALARY:
PROVIDE A DESCRIPTION OF JOB DUTIES IN DETAIL:

DO THE JOB DUTIES AGGRAVATE THE CLAIMANT'S SERVICE-CONNECTED DISABILITIES? (If "Yes," how?)

WHAT IS THE CLAIMANT'S REASON FOR LEAVING EMPLOYMENT? (e.g. resigned, fired, hired for another job)

14. JOB TITLE:
NAME OF EMPLOYER:
DATES OF EMPLOYEMENT
FULL-TIME
PART-TIME
AVERAGE GROSS MONTHLY SALARY:
PROVIDE A DESCRIPTION OF JOB DUTIES IN DETAIL:

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SECTION II: REVIEW OF CLAIMANT'S CIVILIAN EMPLOYMENT HISTORY (Continued)
(If the claimant provides their resume, it is not necessary to duplicate information in Items 10-14. However, the civilian employment
(including self-employment) history must still be discussed to identify any difficulties with job duties, obtaining and maintaining
employment, salary, full time, part-time, and reasons why claimant left job positions).
DO THE JOB DUTIES AGGRAVATE THE CLAIMANT'S SERVICE-CONNECTED DISABILITIES? (If "Yes," how?)

WHAT IS THE CLAIMANT'S REASON FOR LEAVING EMPLOYMENT? (e.g. resigned, fired, hired for another job)

15. HAS THE CLAIMANT EVER HAD DIFFICULTY WITH ANY OF THE FOLLOWING ITEM(S) DUE TO THEIR SCD(s)? (If "Yes," please describe in detail)
CO-WORKER RELATIONS:

JOB PERFORMANCE:

JOB OPPORTUNITIES:

JOB SATISFACTION:

MANAGER RELATIONS:

MISSED TIME AT WORK:

OTHERS:

SECTION III: REVIEW OF CLAIMANT'S MILITARY EMPLOYMENT HISTORY

(If the claimant provides their DD-214 or military records, it is not necessary to duplicate information in Items 16-19. However, the
military employment history must still be discussed to identify any difficulties with job duties, obtaining and maintaining employment,
salary, full time, part-time, and reasons why claimant is unable to perform the job positions.)
CLAIMANT PROVIDED DD-214 OR MILITARY RECORDS (Please complete only fields not on DD-214 or military records)
CLAIMANT DID NOT PROVIDE DD-214 OR MILITARY RECORDS (Please complete section below)
16. LIST CLAIMANT'S MILITARY ENLISTMENT HISTORY

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SECTION III: REVIEW OF CLAIMANT'S MILITARY EMPLOYMENT HISTORY (Continued)
(If the claimant provides their DD-214 or military records, it is not necessary to duplicate information in Items 16-19. However, the
military employment history must still be discussed to identify any difficulties with job duties, obtaining and maintaining employment,
salary, full time, part-time, and reasons why claimant is unable to perform the job positions.)
17. JOB TITLE OR MILITARY OCCUPATIONAL SPECIALTY

18A. NAME OF BRANCH OF SERVICE

18B. DATES OF SERVICE

18C. RANK

19A. NAME OF BRANCH OF SERVICE

19B. DATES OF SERVICE

19C. RANK

SECTION IV: REVIEW OF CLAIMANT'S LEGAL HISTORY
20. IF THE CLAIMANT HAS A HISTORY OF OR IS CURRENTLY DEALING WITH LEGAL ISSUES, SELECT ITEM(S) THAT APPLY AND DESCRIBE BELOW
BANKRUPTCY (In the last seven years)

MISDEMEANOR:

FELON:

PROBATION:

PAROLE:

OTHER:

NOT APPLICABLE

SECTION V: REVIEW OF CLAIMANT'S SUBSTANCE ABUSE HISTORY
21. IF THE CLAIMANT HAS A HISTORY OF OR IS CURRENTLY DEALING WITH SUBSTANCE ABUSE ISSUES, SELECT ITEM(S) THAT APPLY AND DESCRIBE BELOW
ALCOHOL:

ILLEGAL DRUGS:

PRESCRIPTION DRUGS:

OTHER:

NOT APPLICABLE

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SECTION V: REVIEW OF CLAIMANT'S SUBSTANCE ABUSE HISTORY (Continued)
IF THE CLAIMANT HAD A HISTORY OF OR IS CURRENTLY RECEIVING ONGOING TREATMENT(S) FOR SUBSTANCE ABUSE, DESCRIBE TREATMENT PROGRESS
INCLUDING DATE(S) AND LOCATIONS(S) BELOW

SECTION VI: REVIEW OF CLAIMANT'S EDUCATION/TRAINING HISTORY

(If the claimant provided academic or training transcripts, certifications and/or licenses,
please review their educational and/or training history.)
CLAIMANT PROVIDED TRANSCRIPTS, CERTIFICATIONS, AND/OR LICENSES (Do not need to complete all fields in this section.)
CLAIMANT DID NOT PROVIDE DD-214 OR MILITARY RECORDS (Please complete section below)
22. WHAT IS THE HIGHEST LEVEL OF EDUCATION THE CLAIMANT HAS COMPLETED?
SOME HIGH SCHOOL

HIGH SCHOOL

GENERAL EDUCATIONAL DEVELOPMENT (GED) CERTIFICATE

BACHELOR'S DEGREE

MASTER'S DEGREE

POSTGRADUATE DEGREE

ASSOCIATE'S DEGREE

23. IF CLAIMANT HAS EDUCATION BEYOND HIGH SCHOOL, WHAT WAS FIELD OF STUDY (DEGREE MAJOR), IF APPLICABLE?

24. IF CLAIMANT HAS CERTIFICATION OR LICENSES (e.g. Apprenticeship, Journeyman License, Commercial Driver's License (CDL), PLEASE LIST IF APPLICABLE

SECTION VII: REVIEW OF CLAIMANT'S SERVICE-CONNECTED AND NON-SERVICE-CONNECTED DISABILITIES

(Discuss how the claimant's disabilities impact their ability to obtain and maintain employment.)

25. LIST THE CLAIMANT'S SERVICE-CONNECTED DISABILITIES AND IMPAIRMENTS

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SECTION VII: REVIEW OF CLAIMANT'S SERVICE-CONNECTED AND NON-SERVICE-CONNECTED DISABILITIES (Continued)

(Discuss how the claimant's disabilities impact their ability to obtain and maintain employment.)

26. HAS THE CLAIMANT FILED A CLAIM OR IS CLAIMANT RECEIVING INDIVIDUAL UNEMPLOYABILITY (IU) OR TOTAL DISABILITY BASED ON INDIVIDUAL
UNEMPLOYABILITY (TDIU), (If "Yes," discuss in detail)

NOTE: VRC must review for the severity of claimant's SCDs, feasibility, and potential independent living needs.

27. DOES THE CLAIMANT HAVE A VALID DRIVER"S LICENSE? (If "No," please explain reason for not having a valid driver's license)

28. NAME OF MEDICAL TREATMENT FACILITIES THE CLAIMANT IS ATTENDING

29. HOW OFTEN IS THE CLAIMANT SEEN FOR TREATEMENT?

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SECTION VIII: MISCELLANEOUS INFORMATION

(While the following information is not relevant to the entitlement determination, these
questions can assist with referrals, resources, and addressing claimant's needs.)
30. IS CLAIMANT REGISTERED WITH A LOCAL VA
MEDICAL CENTER?
YES

31. IS CLAIMANT REGISTERED WITH
MYHEALTHEVET?

NO

YES

NO

32. DOES THE CLAIMANT REQUIRE A REFERRAL
FOR HUDVASH OR A HOMELESS PROGRAM?
YES

NO

33. CHECK ITEM(S) THAT APPLY IF CLAIMANT IS RECEIVING OR HAS APPLIED FOR BENEFITS BELOW
DISABILITY PENSION (NOT DISABILITY COMPENSATION) (
RETIREMENT (

CIVILIAN

CIVILIAN

MILITARY )

MILITARY )

MEDICARE/MEDICAID
SOCIAL SECURITY DISABILITY INCOME (SSDI OR SSI)
WORKERS COMPENSATION
PROGRAM OF VOCATIONAL REHABILITATION
OTHER:

SECTION IX: COMMENTS
34. OTHER RELEVANT INFORMATION OR ADDITIONAL COMMENTS (Additional information provided during the initial evaluation that is relevant to the entitlement

determination)

35. NAME OF VOCATIONAL REHABILITATION COUNSELOR

36. DATE (MM/DD/YYYY)

PRIVACY ACT INFORMATION: The responses you submit are considered confidential (38 U.S.C. 5701). Your obligation to respond is required in order to obtain benefits. 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. Information that you furnish may be utilized in computer matching
programs with other Federal or State agencies for the purpose of determining your eligibility to receive VA benefits, as well as to collect any amount owed to the United States by virtue of your
participation in any benefit program administered by the Department of Veterans Affairs.
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 2900-0092, and it expires XX/XX/20XX. Public reporting burden for this collection of information is estimated to average 45 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. 2900-0092 in any correspondence. Do not send your completed VA Form 28-1902w to this email address.
VA FORM 28-1902w, XXX 20XX

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