ࡱ> $&#q Z bjbjt+t+ AA<]XXXXXXXllll8 l n p p p p p p $q e X ,XX,,,.XXn llXXXXn ,^,:8 ,XXn  1iV ll.d SCREENING CHECKLIST FOR POSSIBLE DISABILITY (please check any and all that apply)* Consumer has a visible disability (i.e. facial disconfiguration, uses an assistive device, such as wheelchair, etc.). Consumer reports that they have a disability, or recently acquired a disability, that prevents them from working, or from doing the job they are used to doing, or has been fired repeatedly due to disability. Incarceration, history of problems with law, or has a criminal record. Family, friends or doctors report they need help getting a job because they have been unable to do it on their own (due to recent problems with health, lack of motivation, inability in knowing how to do this). Consumer appears to exhibit odd or eccentric behavior, thought patterns, or inability to get along with others. There is a notable deficit in the clients level of work skills compared to others within the same age group and education (such as attention to task, memory, ability to perform multi-step operations, ability to communicate with others, problems with math/reading/spelling). Consumer reports many problems in past employment, has poor or little work history. Consumer reports receiving special education services or IEP in school. Consumer reports history of substance dependency that has occurred, or within last two years, or is current. History of disability in family, receives SSDI, SSI, Food Stamps, TANF, etc. On medications that may suggest disability. *Consult/Refer to Disability Program Navigator if one or more of the above checked. Prepared by M. Lecuyer 2003, Va. Dept. of Rehab. Services -TU   Y Z CJOJQJ5CJOJQJ5CJ OJQJTU*+@AL M   & F$$d%d&d'dTU*+@AL M   X Y Z    W X Y Z $h/ =!"# $@% [0@0 Normal_HmH sH tH <A@< Default Paragraph Font,, Header  !, @, Footer  !\C@\ Body Text Indent$8^8a$56CJ OJQJ^JaJ Z ;;;>Z  Z  Z X[w}w}X[:: GuestVEC Mary LecuyerMary"A:\SCREENING CHECKLIST OneStop.docDTI User`\\DEVSERVER\InetPub\wwwroot\testsite\PromisingPractices\Downloads\VA DPN SCREENING CHECKLIST.docfXdC:ztdh^`OJQJ^Jo(hHo^`OJPJQJ^Jo(hpp^p`OJQJo(hHh@ @ ^@ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohPP^P`OJQJo(hHh^`CJOJQJo(q^`OJPJQJ^Jo(hpp^p`OJQJo(hHh@ @ ^@ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohPP^P`OJQJo(hHfXC:zt@V8Z@GzTimes New Roman5Symbol3& zArialE5  Lucida ConsoleO& k9?Lucida Sans Unicode?5 zCourier New;Wingdings"qhffff:x  6 !200 RSCREENING CHECKLIST FOR POSSIBLE DISABILITY (please check any and all that apply)*GuestDTI UserOh+'0$0D Xd    SSCREENING CHECKLIST FOR POSSIBLE DISABILITY (please check any and all that apply)*CREGuestINuesues Normal.dotH DTI UsertH2I Microsoft Word 8.0 @@2f]@4&RV @4&RV  ՜.+,D՜.+,\ hp  ;#Richmond Career Advancement Center 01 SSCREENING CHECKLIST FOR POSSIBLE DISABILITY (please check any and all that apply)* Title@%Qq _PID_GUID_AdHocReviewCycleID_EmailSubject _AuthorEmail_AuthorEmailDisplayNameAN{5D510978-0DEF-495C-B7EC-FA57F19821D7}i[,$Update to State and Local ResourcesTillmon.Chonita@dol.govTillmon, Chonita - ETA CTRe  !"%Root Entry F@(U iV '1Table WordDocumentSummaryInformation(DocumentSummaryInformation8CompObjjObjectPooliV iV   FMicrosoft Word Document MSWordDocWord.Document.89q