*The following forms can be completed online and then printed.
**These forms cannot be filled in online. They may be printed out and filled in by hand.
Authorization for disclosure of personal and health information form
Bureau of Developmental Disabilities Services
- Application for developmental disabilities services (state form 55068)
- Confirmation of Diagnosis (state form 54727)
Deaf and Hard of Hearing Services
- Interpreter service program communication request
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.
- Indiana interpreter certificate application 49978
Used to determine whether applicant meets criteria to be an IIC interpreter.
- Indiana interpreter certificate application for renewal
- Indiana interpreter certificate or identification replacement card application
- Indiana interpreter certificate CEU
- DHHS CEU sponsorship approval 51381
- Block grant plan of action 54038
- Block grant daily log 54037
- Block grant monthly report 48203
Enables DHHS to ascertain that the 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 case management services can be measured using this information.
- Social Services Block Grant application and services registration 49452
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.
Vocational Rehabilitation Services
- Commission on rehabilitation counselor certification - verification of attendance 26460**
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**
All individuals who have completed their VRS program are given a customer satisfaction survey form to respond to questions about the quality and effectiveness of VRS services provided to them. This information is used to evaluate the way VRS services can be improved or made more effective for people with disabilities.
- Commission on Rehabilitation Services - satisfaction survey - large print version 49823**
All individuals with visual impairments who have completed their VRS service programs are given a large print customer satisfaction survey form to respond to questions about the quality and effectiveness of VRS services provided to them. This information is reviewed to determine how VRS services to visually impaired individuals may be improved.
- Commission on Rehabilitation Services - satisfaction survey for customers with pre-lingual deafness 49603**
Pre-lingual deaf individuals who have completed their VRS service program are given a customer satisfaction survey form that asks questions about VRS services provided to them in a simplified language format. This information is used to evaluate the manner VRS services are provided to deaf individuals to make the VRS program more responsive to their vocational and communication needs.
- DDRS 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 VRS services. The VRS customer fills out this form on his own.
- Financial aid communications 41378**
Used to provide the VRS counselor with information from college financial aid office as to the amount of financial assistance VRS can provide to the student. This form is utilized each academic year by the VRS counselor for all VRS post secondary student/customers.
Blind & Visually Impaired Services
- Confidential report of blindness or visual impairment 48126**
- Referral for services for the blind and visually impaired 46206**
This is the referral form for BVIS services and programs.