VOCATIONAL REHABILITATION COUNSELING RECORD

Job Interests/Expressed Career Goal:



Cell Phone:
Fax #:
Beeper #:
E-Mail name:


1.  Are you employed now?         Date last worked?
2.  Do you have a typed resume you can give me?            
3.  Have you applied for any jobs in the last 3 months?  
4.  Do you wish to return to work in the labor market ?   
5.  When did you last have contact with your employer or supervisor?  
6.  May we contact your present employer?               
7.  Are you prevented from lawfully becoming employed in this country because of Visa or  Immigration status?		                         
8.  When requested, can you provide genuine documentation establishing your identity and eligibility to be legally  employed in the United States?
9.  On what date would you be available for work?	   					
10. Are you available to work?          
    [] Full time  [] Part time  [] Shift work  []Temporary
11. Are you a member of a union?			
    If yes, name?
12. Do you have a valid drivers license now?                   
13. Do you have a functional motor vehicle now?          
14. Can you travel if a job requires it?                             
15. Please take a look at the telephone directory sent by your phone company to your home.
    What Area [County] & what towns are listed on the cover or the book binder?
16. What are the major newspapers in your area?
17. Do you read:     
    ___ Rarely    ___ Occasionally    ___ Frequently
    What types of material do you read?:
18. Do you consider yourself computer literate?              
19. Do you have working computer in the home?            
20. Do you have an Internet account at home?               
21. Have you ever had career testing?		      
    If yes, where & when?
22. Are you expecting to enroll or start school soon?         
23. Do you possess a library card?                                    
    If yes, which library?
24. What are your salary expectations?:   
    $     hourly rate OR $    Annual Rate
25. Have you applied for Social Security Disability [SSDI]?							    26.  What are your hobbies, special interests, hands-on activities, and past time activities?:
27. What types of volunteer or community work have you done?									                   28.  What questions or concerns would you like to discuss?
29. Do you have any physical limitations that preclude you from performing any work for which  you expect to be considered?			       
30. If yes, what can be done to accommodate your limitations?
    Please describe							                   
31. Are you bondable?			                   
32. Please list all your current licenses, certifications, & accreditations:


EMPLOYMENT EXPERIENCE:
Employer:
Dates employed from  to
Address:
Hourly salary/rate: $
Job Title:
Supervisor:
Phone:
Work Performed [describe]:

Employer:
Dates employed from  to
Address:
Hourly salary/rate:  $
Job Title:
Work Performed [describe]:
Supervisor:     Phone:
Reason for leaving:

Employer:
Dates employed from  to
Address:
Hourly salary/rate:  $
Job Title:
Work Performed [describe]:
Supervisor:     Phone:
Reason for leaving:

Employer:
Dates employed from  to
Address:
Hourly salary/rate:  $
Job Title:
Work Performed [describe]:
Supervisor:     Phone:
Reason for leaving:

Employer:
Dates employed from  to
Address:
Hourly salary/rate:  $
Job Title:
Work Performed [describe]:
Supervisor:     Phone:
Reason for leaving:

Employer:
Dates employed from  to
Address:
Hourly salary/rate:  $
Job Title:
Work Performed [describe]:
Supervisor:     Phone:
Reason for leaving:

Employer:
Dates employed from  to
Address:
Hourly salary/rate:  $
Job Title:
Work Performed [describe]:
Supervisor:     Phone:
Reason for leaving:

Employer:
Dates employed from  to
Address:
Hourly salary/rate:  $
Job Title:
Work Performed [describe]:
Supervisor:     Phone:
Reason for leaving:

Employer:
Dates employed from  to
Address:
Hourly salary/rate:  $
Job Title:
Work Performed [describe]:
Supervisor:     Phone:
Reason for leaving:

Employer:
Dates employed from  to
Address:
Hourly salary/rate:  $
Job Title:
Work Performed [describe]:
Supervisor:     Phone:
Reason for leaving:

SPECIAL SKILLS & QUALIFICATIONS:
[Summarize special skills and qualifications acquired from employment or other experience. 
This can include any licenses; certifications; knowledge of work tools, equipment, or 
special machinery; computer literacy; special accomplishments; supervisory experience; 
on-the-job training, specialized courses, etc.]:





Any special skill areas or equipment operated which the claimant self-identified are checked below:
				 		
____ Calculator		    	  
____ Fax	              	                           
____ Lotus 1-2-3
____ PBX system
____ PC 
____ Production/mobile machinery:
____ Standard transmission auto
____ Typewriter 
____ Word Perfect


EDUCATION:
                     Elementary       High        College
School name:
Years completed:
Diploma/Degree:
Describe course:
 of study/grades


Describe all Specialized training; apprenticeship; trade school; voc-tech school; business; correspondence; or adult education, etc.

Honors Received:

VETERAN OF THE U.S. MILITARY SERVICE?
If yes,  Branch:
Dates of Service:
Discharge Rank:
Primary Duties:
Training Received:


LANGUAGES
          Fluent    Good     Fair
SPEAK:
READ :
WRITE:


LIST PROFESSIONAL, TRADE, BUSINESS, OR CIVIC ACTIVITIES AND OFFICES HELD:

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