Forms
The following forms can be completed online and then printed.
450B Attachment for the Aged and Disabled Waiver, the Medically Fragile Children Waiver and the TBI Waiver 48115/HCBS 0011
Identifies any mental health conditions the client may have, for example, is there a diagnosis of mental illness or mental retardation/developmental disabilities.
Alzheimer's / Dementia Special Care Unit 48896/BAIS 0005
Used to implement IC 12-10-5.5. Long Term Care facilities with special programs or units that are advertised or promoted as providing special care must submit a copy of the form annually. Copies of the completed forms are available to consumers who need the services provided in the SCUs.
Application for Long-Term Care Services 45943/BAIS 0018
This application provides client demographic information. Used for multiple programs such as the Home and Community Based Services (HCBS)-for the Medicaid Waivers, CHOICE, SSBG, etc., as well as for the Pre-Admission Screening/Pre-Admission Screening Resident Review (PAS/PASRR) programs.
Community Vocational/Habilitation Survey 51680/BQIS 0004 (Wprd document)
DHHS CEU Sponsorship Approval 51381/DHHS 0011
Disclosure for Housing with Services Establishments 49028/BAIS 0001
All assisted facilities, Residential Care Facilities and county homes are to complete this form annually and when there are any major changes.
Incident Report 51677 (in Excel)
Indiana Interpreter Certificate Application 49978/DHHS 0004
Used to determine whether applicant meets criteria to be an IIC interpreter.
Interpreter Service Program 46812/DHHS 0001
Enables DHHS to ascertain that the interpreting services are within the specific guidelines when they were provided at state agencies or state functions. Statistics are compiled from this form on who was being served, which state agencies utilize this service, number of hours, etc. The quality of interpreting services can be measured using the information provided.
Notice of Action 46015/HCBS 0005
Used to provide decisions being rendered for a client through the HCBS programs.
PASARR Level I - Identification Evaluation Criteria - Certification by Physician for Long-Term Care Services 45277/Form 450B/PASRR2A
Completed by the physician, PAS Agency assessor, hospital discharge planner or the nursing facility. The purpose is for the federally required PASRR screening for all individuals requesting admission to a nursing facility, to determine if the individuals might possibly be mentally ill or mentally retarded and therefore require further assessment (Level II) to determine if they can be admitted to the facility. This form can also be used to screen residents in a nursing facility who have undergone a change in condition and may require a PASRR Level II assessment to determine if they can remain in the facility. NOTE: This form is generally known as the PASRR Level I, and is also known as the form 450B/PASRR2A, Sections IV and V, Part A.
Plan of Care (multi) 45994/BAIS 0019
Used to track the HCBS for a client. It is a summary of the services being provided or recommended for the client.
Post-Transition Quality Assurance Checklist 51681/BQIS 0005 (Word document)
Post-Transition Quality Assurance Checklist 51682/BQIS 0006 (Word document)
Pre-Transition Quality Assurance Checklist 51683/BQIS 0007 (Word document)
Pre-Transition Quality Assurance Checklist 51684/BQIS 0008 (Word document)
Provider Standards Agency Survey 51678/BQIS 0002 (Word document)
Residential Services and Supports Survey 51679/BQIS 0003 (Word document)
Social Services Block Grant 48203/DHHS 0002
Enables DHHS to ascertain that the interpreting and case management services are within the specified federal guidelines. Statistics are compiled from this form on who was being served, number of hours, etc. The quality of interpreting and case management services can be measured using this information.
These forms cannot be filled in online. They may be printed out and filled in by hand or typewriter.
Aplicacion Y Referido DDARS 47131/VRS 0016S
Hispanic individuals wishing to apply for VRS services are asked by the VR counselor to fill out this application form written in Spanish. The referral agency may assist the Hispanic individual filling out this application form if the applicant's literacy level requires assistance in completing this form.
Application for the Residential Care Assistance Program 37113/BAIS 0030
The caseworkers in all of the 92 local OFC utilize this form to enroll applicants in the RCAP. RCAP facilities and County Homes also have access to this form and complete it for residents then send it to the OFC.
Assistance to Residents in County Homes / Room and Board Assistance Budget and Recommendation 31759/BAIS 0005B
Used by caseworkers to determine the financial eligibility of residents in the RCAP. Used at the time of the initial applications, annual re-determinations, changes, and closures.
Autism Spectrum Disorders--Indiana's Comprehensive State Plan to Guide Services
Certification of Disability for Non-Vocation Rehabilitation Programs 36918/VRS 2004
Used by the VR counselor to certify that the individual is disabled and that the disability constitutes a substantial impediment to employment. Disabled individuals applying for federal government jobs in Indiana may be required to certify their disability in order to be given an opportunity to demonstrate their ability to function in federal jobs of their choice. This form is required by the federal government to permit disabled individuals to perform in specific federal positions on a trial basis.
Chronological Narrative 46014/HCBS 0008
Used by care managers to document case records regarding the client's situation/status. This is a formal documentation record.
Commission on Rehabilitation Counselor Certification - Verification of Attendance 26460/VRS 2064
Used to verify attendance by rehabilitation counselors at CEU approved training conferences, workshops, seminars, and other educational programs so they may earn continuing education credits required to keep their Certified Rehabilitation Counselor certificates. CRC counselors are required to accumulate a specific number of CEU's each year in order to qualify to work as CRC counselors.
Commission on Rehabilitation Services Customer Satisfaction Survey 46098/VRS 0007
All individuals who have completed their VR program are given a Customer Satisfaction Survey form to respond to questions about the quality and effectiveness of VR services provided to them. This information is used to evaluate the way VR services can be improved or made more effective for people with disabilities.
Commission on Rehabilitation Services - Satisfaction Survey - Large Print Version 49823/VRS 0007A
All individuals with visual impairments who have completed their VR service programs are given a large print Customer Satisfaction Survey form to respond to questions about the quality and effectiveness of VR services provided to them. This information is reviewed to determine how VR services to visually impaired individuals may be improved.
Commission on Rehabilitation Services - Satisfaction Survey for Customers with Pre-Lingual Deafness 49603/VRS 0019
Pre-lingually deaf individuals who have completed their VR service program are given a Customer Satisfaction Survey form that asks questions about VR services provided to them in a simplified language format. This information is used to evaluate the manner VR services are provided to deaf individuals to make the VRS program more responsive to their vocational and communication needs.
Community Vocational/Habilitation Survey 51680/BQIS 0004
Confidential Report of Blindness or Visual Impairment 48126/BVIS 0007
Consent for Disclosure of Information 42224/VRS 0014
Used to request confidential information about VR customers from schools, physicians, rehabilitation center programs, hospitals, and other programs. This information is needed by the VR counselor to develop a plan of services for the VR customer, and cannot be obtained without the written permission of the individual, his or her parents, guardian or other persons authorized to provide this permission as required by law.
DDARS Referral and Application 10057
Used when an individual applies for services from VRS or the Bureau of Developmental Disabilities Services. The VRS or the BDDS counselor obtains background information about the individual to assist in an evaluation of the individual's eligibility for services for either division. This questionnaire is given to individuals who apply for VR services. The VR customer fills out this form on his own.
Deaf and Hard of Hearing Services - Interpreter Service Program (ISP) / Social Services Block Grant (SSBG) Application and Services Registration 49452/DHHS 0003
Enables DHHS staff to keep statistics on the number of people we serve along with other information such as age, gender, sex, and so forth.
Definition of Specialized Services for PAS/ARR 46921/BAIS 0023
Provides the definition for Specialized Services for clients being screened through the federal PASRR program.
Employment Questionnaire 04677/VRS 2060
This questionnaire is given to individuals who apply for VR services. Some individuals are still working when they apply for VR services, so it is necessary to provide the VR counselor with the details about his or her job in order to help determine what services may be needed to assist the individual in retaining employment or obtaining a new job. The VR customer fills out his form on their own.
Financial Aid Communications 41378/VRS 0006
Used to provide the VR counselor with information from college financial aid office as to the amount of financial assistance VR can provide to the student. This form is utilized each academic year by the VR counselor for all VR post secondary student/customers.
How Are We Doing? 47234/VRS 0009
Completed voluntarily by customers while receiving VR services. These cards are available only in VRS Region II and III.
How Are We Doing? 47204/VRS 0015
Completed voluntarily by customers while receiving VR services.
Indiana PAS/PASRR Program Fax Cover Sheet 47178/BAIS 0025
Used for PAS/PASRR/RR cases that are faxed into the office for review, data entry, and appropriate processing.
Indiana PASARR/MI Program - CMHC ARR Referral Checklist 47184/BAIS 0031
Used as an aid for the CMHCs in order to track referrals.
Indiana PASARR Program - Dementia Assessment Checklist 47182/BAIS 0029
Used by the Area Agencies on Aging, nursing facilities, and CMHCs to identify a client's level of cognitive impairment (Dementia/Alzheimer). It provides a list of qualifiers when determining cognitive impairment.
Indiana PASRR Program - Screen for Depression 47179/BAIS 0026
Used to determine a client's level of depression, the intensity and duration of the depression symptoms.
Information Required in an Emergency 46213
Used for blind individuals receiving services at the Bosma Center for the Blind. In case of injury or illness while at the Center, the caseworker would fill out this form so the blind individual would receive emergency medical care. This form is used to authorize the BVIS to obtain emergency medical and/or hospital services.
Monthly Report of Vending Income 29885/BVIS 0003
Used by private commercial vendors who contract with the state to provide vending services on Interstate Highway Rest Areas. The vendors are reporting sales of products and costs on a monthly basis.
Plan of Care / Cost Comparison Budget for the Aged and Disabled Waiver 42822/HCBS 1D/2D
Used for the Medicaid waiver programs. This form lists the services required in order to meet the client's needs through the HCBS specific waiver (i.e. for the Aged and Disabled Waiver, AL, Medically Fragile Children's Waiver, TBI)
Plan of Care / Cost Comparison Budget for the AL and AFC Waiver 50149/HCBS 1F/2F
Used for the Medicaid waiver programs. This form lists the services required in order to meet the client's needs through the HCBS specific waiver (i.e. for the Aged and Disabled Waiver, AL, Medically Fragile Children's Waiver, TBI)
Plan of Care / Cost Comparison Budget for the Autism Waiver 46020/HCBS 1B/2B
Used by the Targeted Case Manager to submit to the State's Autism Waiver Specialist all proposed services and units of service for each Autism Waiver recipient. This form identifies the needs and goals of the client with an explanation of how these needs and goals will be met by the proposed services and units. Once approved by the State, this form becomes part of the client's permanent record and is used to identify what services should be delivered to the client.
Plan of Care / Cost Comparison Budget for the Medically Fragile Children Waiver 46019/HCBS 1C/2C
Used for the Medicaid waiver programs. This form lists the services required in order to meet the client's needs through the HCBS specific waiver (i.e. for the Aged and Disabled Waiver, AL, Medically Fragile Children's Waiver, TBI)
Plan of Care / Cost Comparison Budget for the TBI Waiver 49413/HCBS 1E/2E
Used for the Medicaid waiver programs. This form lists the services required in order to meet the client's needs through the HCBS specific waiver (i.e. for the Aged and Disabled Waiver, AL, Medically Fragile Children's Waiver, TBI)
Post-Transition Quality Assurance Checklist 51681/BQIS 0005
Post-Transition Quality Assurance Checklist 51682/BQIS 0006
Pre-Transition Quality Assurance Checklist 51683/BQIS 0007
Pre-Transition Quality Assurance Checklist 51684/BQIS 0008
Provider Standards Agency Survey 51678/BQIS 0002
Recommendation of County Office - Assistance to Residents in County Homes - Room and Board Assistance 18438/BAIS 0052
Used by caseworkers in the Office of Family and Children as a record keeping device.
Referral for Services for the Blind and Visually Impaired 46206/BVIS 0002
This is the referral form for BVIS services and programs.
Report of Hearing and Ear Assessment 35055/VRS 2051
Used by the VR counselor to confirm via examination by an otologist that an individual has a diagnosis of hearing impairment and provides the prognosis and recommendations for treatment.
Request for Information Mortality Review 53266/QA 2000
Statement of Book Expense 13734/VRS 0008
Used to compensate VR students for the cost of books required by the college or university training program.
Student Health Survey 04290/VRS 2055
Request for personal information by the Vocational Rehabilitation Counselor as to the reasons a VR student has been hospitalized or is being treated by a physician for a health problem that may be interfering with the student's ability to attend classes. All information is confidential as per 34 CFR 361.49.
Support Service Expense Statement 13729/VRS 0011
VR students who need assistance in going to and from classes or receive other support services needed to participate in a college setting are required to obtain a statement from the support service provider as to the type of services provided and when.
Vocational Rehabilitation Services: Final Plan Amendment 04205VRS 2031
Used by the VR counselor when the individual is no longer eligible for VR services or the case is being closed as a result of achieving an employment outcome, and whether post-employment services will or will not be provided. The applicant/customer statement section of Part B of this document provides instructions for appealing closures by the VR counselor.
Worksheet for Data Entry - Termination or Denial 43714
Provides an overview of the action taken for a client who has applied for HCBS.
