VA Form 28-1902W Rehabilitation Needs Inventory (Rni)

What Is VA Form 28-1902w?

VA Form 28-1902w, Rehabilitation Needs Inventory (RNI) is a form used to provide the VA information about the veteran's educational and vocational needs. The Department of Veteran Affairs (VA) uses this information to find the appropriate job or educational program for a veteran.

VA 28-1902w belongs to VA 28-1902 series, which is used to provide veterans with a new career and vocational opportunities. These forms are used by counseling psychologists, vocational rehabilitation counselors and contract counselors for controlling process and results of counseling and evaluation activities. The other forms in the series are:

The latest version of the form was released by the VA in September 2015 with all previous editions obsolete. A fillable VA Form 28-1902w is available for download below or can be found through the VA website.

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OMB Control No. 2900-0092
Respondent Burden: 45 Minutes
Expiration Date: 08-31-2018
REHABILITATION NEEDS INVENTORY (RNI)
Privacy Act Notice: 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., to determine entitlement to vocational rehabilitation benefits and to plan a program of rehabilitation
services) as identified in the VA system of records, 58VA21/22/28, Compensation, Pension, Education, and Vocational Rehabilitation and Employment Records - VA,
published in the Federal Register. Your obligation to respond is voluntary. Giving us your SSN account information is voluntary. Refusal to provide your SSN by itself
will not result in the denial of benefits. VA will not deny an individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by a
Federal Statute of law in effect prior to January 1, 1975, and still in effect. Information submitted is subject to verification through computer matching programs with
other agencies.
Respondent Burden: We need this information for educational and vocational planning to help you make the best use of your vocational rehabilitation benefits.
Title 38, United States Code chapter 31, allows us to ask for this information. We estimate that you will need an average of 45 minutes to review the instructions, find
the information, and complete this form. VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. You are not
required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can be located on the OMB Internet Page at
http://www.reginfo.gov/public/do/PRAMain. If desired, you can call 1-800-827-1000 to get information on where to send comments or suggestions about this form.
(First, middle, last)
1. NAME
2. TELEPHONE NUMBER(S)
HOME PHONE NUMBER CELL PHONE NUMBER
WORK PHONE NUMBER
3. CURRENT ADDRESS
4a. E-MAIL ADDRESS 1
4b. E-MAIL ADDRESS 2
5. GENDER
6. MARITAL STATUS
7. CLAIM NUMBER
8. SOCIAL SECURITY NUMBER
MALE
FEMALE
9. CLAIMING DEPENDENTS?
10. NICKNAME/AKA
11. EMERGENCY CONTACT INFORMATION
CONTACT NAME
YES
NO
#
CONTACT PHONE NUMBER
CONTACT RELATIONSHIP
12. HOW DO YOU EXPECT THIS PROGRAM TO HELP YOU?
13. WHAT ARE THE JOBS OR CAREER FIELDS YOU ARE MOST INTERESTED IN?
14. HAVE YOU EVER PARTICIPATED IN OR ARE CURRENTLY PARTICIPATING IN A VA EDUCATION BENEFIT PROGRAM?
YES
NO
14A. HAVE YOU EVER PARTICIPATED
14B. CHECK ALL THAT APPLY IN WHICH YOU HAVE PARTICIPATED
IN A PROGRAM OF VOCATIONAL
WORKER'S COMP
PRIVATE
REHABILITATION BEFORE?
(Please explain)
STATE VOCATIONAL REHABILITATION
OTHER
YES
NO
VA VOCATIONAL REHABILITATION
(If "Yes," complete Items 14B and 14C)
(i.e., training, medical, vocational testing, functional capacities, job search activities):
14C. LIST ANY TYPE OF SERVICES YOU WERE PROVIDED
EMPLOYMENT
Please fill out each area as completely as possible. If you have a resume, please attach it.
15. CIVILIAN EMPLOYMENT HISTORY: Please start with your most current position.
JOB TITLE
DATES
AVERAGE GROSS
MONTHLY SALARY
FROM
TO
COMPANY NAME
STATUS
TEMPORARY ASSIGNMENT OR CONTRACT
PART TIME
A
PERMANENT POSITION
FULL TIME
DESCRIBE JOB DUTIES IN DETAIL
REASON FOR LEAVING
JOB TITLE
DATES
AVERAGE GROSS
MONTHLY SALARY
FROM
TO
B
COMPANY NAME
STATUS
TEMPORARY ASSIGNMENT OR CONTRACT
PART TIME
PERMANENT POSITION
FULL TIME
28-1902w
VA FORM
SUPERSEDES VA FORM 28-1902w, FEB 2012,
SEP 2015
WHICH WILL NOT BE USED
OMB Control No. 2900-0092
Respondent Burden: 45 Minutes
Expiration Date: 08-31-2018
REHABILITATION NEEDS INVENTORY (RNI)
Privacy Act Notice: 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., to determine entitlement to vocational rehabilitation benefits and to plan a program of rehabilitation
services) as identified in the VA system of records, 58VA21/22/28, Compensation, Pension, Education, and Vocational Rehabilitation and Employment Records - VA,
published in the Federal Register. Your obligation to respond is voluntary. Giving us your SSN account information is voluntary. Refusal to provide your SSN by itself
will not result in the denial of benefits. VA will not deny an individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by a
Federal Statute of law in effect prior to January 1, 1975, and still in effect. Information submitted is subject to verification through computer matching programs with
other agencies.
Respondent Burden: We need this information for educational and vocational planning to help you make the best use of your vocational rehabilitation benefits.
Title 38, United States Code chapter 31, allows us to ask for this information. We estimate that you will need an average of 45 minutes to review the instructions, find
the information, and complete this form. VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. You are not
required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can be located on the OMB Internet Page at
http://www.reginfo.gov/public/do/PRAMain. If desired, you can call 1-800-827-1000 to get information on where to send comments or suggestions about this form.
(First, middle, last)
1. NAME
2. TELEPHONE NUMBER(S)
HOME PHONE NUMBER CELL PHONE NUMBER
WORK PHONE NUMBER
3. CURRENT ADDRESS
4a. E-MAIL ADDRESS 1
4b. E-MAIL ADDRESS 2
5. GENDER
6. MARITAL STATUS
7. CLAIM NUMBER
8. SOCIAL SECURITY NUMBER
MALE
FEMALE
9. CLAIMING DEPENDENTS?
10. NICKNAME/AKA
11. EMERGENCY CONTACT INFORMATION
CONTACT NAME
YES
NO
#
CONTACT PHONE NUMBER
CONTACT RELATIONSHIP
12. HOW DO YOU EXPECT THIS PROGRAM TO HELP YOU?
13. WHAT ARE THE JOBS OR CAREER FIELDS YOU ARE MOST INTERESTED IN?
14. HAVE YOU EVER PARTICIPATED IN OR ARE CURRENTLY PARTICIPATING IN A VA EDUCATION BENEFIT PROGRAM?
YES
NO
14A. HAVE YOU EVER PARTICIPATED
14B. CHECK ALL THAT APPLY IN WHICH YOU HAVE PARTICIPATED
IN A PROGRAM OF VOCATIONAL
WORKER'S COMP
PRIVATE
REHABILITATION BEFORE?
(Please explain)
STATE VOCATIONAL REHABILITATION
OTHER
YES
NO
VA VOCATIONAL REHABILITATION
(If "Yes," complete Items 14B and 14C)
(i.e., training, medical, vocational testing, functional capacities, job search activities):
14C. LIST ANY TYPE OF SERVICES YOU WERE PROVIDED
EMPLOYMENT
Please fill out each area as completely as possible. If you have a resume, please attach it.
15. CIVILIAN EMPLOYMENT HISTORY: Please start with your most current position.
JOB TITLE
DATES
AVERAGE GROSS
MONTHLY SALARY
FROM
TO
COMPANY NAME
STATUS
TEMPORARY ASSIGNMENT OR CONTRACT
PART TIME
A
PERMANENT POSITION
FULL TIME
DESCRIBE JOB DUTIES IN DETAIL
REASON FOR LEAVING
JOB TITLE
DATES
AVERAGE GROSS
MONTHLY SALARY
FROM
TO
B
COMPANY NAME
STATUS
TEMPORARY ASSIGNMENT OR CONTRACT
PART TIME
PERMANENT POSITION
FULL TIME
28-1902w
VA FORM
SUPERSEDES VA FORM 28-1902w, FEB 2012,
SEP 2015
WHICH WILL NOT BE USED
15. CIVILIAN EMPLOYMENT HISTORY (CONTINUED)
DESCRIBE JOB DUTIES IN DETAIL
B
REASON FOR LEAVING
JOB TITLE
DATES
AVERAGE GROSS
MONTHLY SALARY
FROM
TO
COMPANY NAME
STATUS
TEMPORARY ASSIGNMENT OR CONTRACT
PART TIME
C
PERMANENT POSITION
FULL TIME
DESCRIBE JOB DUTIES IN DETAIL
REASON FOR LEAVING
JOB TITLE
DATES
AVERAGE GROSS
MONTHLY SALARY
FROM
TO
COMPANY NAME
STATUS
TEMPORARY ASSIGNMENT OR CONTRACT
PART TIME
D
PERMANENT POSITION
FULL TIME
DESCRIBE JOB DUTIES IN DETAIL
REASON FOR LEAVING
16. MILITARY WORK HISTORY: What did you do in the military? Please fill out the following area as completely as possible.
Please start with your last assignment.
HIGHEST RANK ACHIEVED:
ARMED SERVICES:
ARMY
NAVY
AIR FORCE
MARINES
COAST GUARD
JOB TITLE
DATES
AVERAGE GROSS
MONTHLY SALARY
FROM
TO
A
LIST ANY HONORS AND COMMENDATIONS
RANK
DESCRIBE JOB DUTIES IN DETAIL
HIGHEST RANK ACHIEVED:
ARMED SERVICES:
ARMY
NAVY
AIR FORCE
MARINES
COAST GUARD
JOB TITLE
DATES
AVERAGE GROSS
MONTHLY SALARY
FROM
TO
B
LIST ANY HONORS AND COMMENDATIONS
RANK
DESCRIBE JOB DUTIES IN DETAIL
HIGHEST RANK ACHIEVED:
ARMED SERVICES:
ARMY
NAVY
AIR FORCE
MARINES
COAST GUARD
JOB TITLE
DATES
AVERAGE GROSS
MONTHLY SALARY
FROM
TO
C
LIST ANY HONORS AND COMMENDATIONS
RANK
DESCRIBE JOB DUTIES IN DETAIL
17. WOULD IT BE POSSIBLE FOR YOU TO RETURN TO WORK IN A FORMER OCCUPATION OR FOR A FORMER EMPLOYER?
YES
NO
VA FORM 28-1902w, SEP 2015
Page 2
MILITARY WORK HISTORY (CONTINUED)
18. WHAT WORK SKILLS DID YOU USE IN YOUR PREVIOUS POSITIONS THAT YOU THINK YOU MAY BE ABLE TO USE IN A NEW JOB?
19. PLEASE EXPLAIN WHAT YOU DID DURING PERIODS OF UNEMPLOYMENT 3 MONTHS OR LONGER:
EDUCATION AND TRAINING
Please fill out the area below regarding your education/training background as completely as possible.
Please include vocational, college, on-the-job, and other training. NOTE: Please include civilian and military schools/training.
20. MARK HIGHEST LEVEL COMPLETED:
SOME HS - HIGHEST GRADE COMPLETED:
HS - YEAR
GED - YEAR
ASSOCIATE
BACHELOR
MASTER
DOCTORAL
21D.
21B. DATES (MM/YYYY)
21F. DEGREE (if any),
21C.
21E. MAJOR COURSE
CREDITS/
21A. NAME OF SCHOOL
GPA
CLOCK
OF STUDY
YEAR RECEIVED
HOURS
FROM
TO
22A. WHAT SUBJECTS DID YOU LIKE?
22B. WHAT SUBJECTS DID YOU DISLIKE?
1
1
2
2
3
3
23B. LIST CERTIFICATES/LICENSES
23C. DATE
23A. DO YOU HAVE ANY CURRENT VOCATIONAL
(Apprentices or journeyman card, truck driver/CDL, etc.)
CERTIFICATES AND/OR LICENSES?
EXPIRES
1
YES
NO
2
(If "Yes," complete Items 23B and 23C)
3
24. HAVE YOU BEEN DIAGNOSED WITH A LEARNING DISABILITY? (If "Yes," please describe below):
DISABILITIES
List and describe your service-connected disability(ies). Please list the disability(ies) in order of severity.
25C. WHAT DIFFICULTIES ARE YOU EXPERIENCING DUE TO YOUR
25B. RATING
25A. SERVICE-CONNECTED DISABILITY
(%)
DISABILITIES?
26C. WHAT DIFFICULTIES ARE YOU EXPERIENCING DUE TO YOUR
26A. NON SERVICE-CONNECTED
26B. RATING
DISABILITY
(%)
DISABILITIES?
(Check all that apply)
27. HAS YOUR SERVICE-CONNECTED DISABILITY(IES) AFFECTED YOU IN THE FOLLOWING AREAS OF WORK?
OTHER (Please explain)
JOB PERFORMANCE
JOB OPPORTUNITIES
CO-WORKER RELATIONS
JOB SATISFACTION
MISSED WORK TIME
MANAGER RELATIONS
VA FORM 28-1902w, SEP 2015
Page 3
DISABILITIES (CONTINUED)
28. ARE ANY OF YOUR DISABILITIES IMPROVING?
29. ARE YOUR DISABILITIES STABLE?
30. ARE ANY OF YOUR DISABILITIES WORSENING?
YES
NO
YES
NO
YES
NO
(Check all that apply)
31. DO YOU RECEIVE ANY OF THE FOLLOWING?
RETIREMENT (Military/civilian)
WORKERS COMPENSATION BENEFITS
WELFARE ASSISTANCE
DISABILITY PENSION (Military/civilian)
SOCIAL SECURITY DISABILITY INCOME (SSDI/SSI)
MEDICARE/MEDICAID
UNEMPLOYMENT
ALIMONY/CHILD SUPPORT
OTHER
(Check all that apply)
32. DO YOU HAVE A CLAIM PENDING FOR ANY OF THE FOLLOWING?
RETIREMENT (Military/civilian)
WORKERS COMPENSATION BENEFITS
WELFARE ASSISTANCE
DISABILITY PENSION (Military/civilian)
SOCIAL SECURITY DISABILITY INCOME (SSDI/SSI)
MEDICARE/MEDICAID
UNEMPLOYMENT
ALIMONY/CHILD SUPPORT
OTHER
MEDICAL TREATMENT
Please describe medical treatment you have received or are receiving.
33B. NAME OF VA OR PRIVATE
33C. HOW OFTEN SEEN
33A. CONDITION
33D. MEDICATION(S) PRESCRIBED
MEDICAL FACILITY
FOR TREATMENT
34B. WHAT DO YOU NEED?
34A. DO YOU HAVE MEDICAL NEEDS
THAT ARE NOT BEING MET?
YES
NO
(If "Yes," complete Item 34B)
35B. PLEASE DESCRIBE YOUR ADAPTIVE EQUIPMENT
35A. DO YOU USE ANY ADAPTIVE
EQUIPMENT SUCH AS BRACES,
ARTIFICIAL LIMBS, HEARING AIDS,
ETC?
YES
NO
(If "Yes," complete Item 35B)
36A. ARE THERE OTHER PROBLEMS
36B. PLEASE LIST OTHER PROBLEMS OR ISSUES WITH WHICH YOU WOULD LIKE HELP
OR ISSUES WITH WHICH YOU
WOULD LIKE HELP?
YES
NO
(If "Yes," complete Item 36B)
37. DO YOU HAVE ANY PENDING VA CLAIMS?
38. DO YOU NEED INFORMATION ABOUT OTHER VA BENEFITS OR PROGRAMS?
(If "Yes," please describe below)
(If "Yes," please describe below)
YES
NO
YES
NO
MISCELLANEOUS
The following information will be used for employment planning purposes.
39C. DESCRIBE YOUR CURRENT LIVING SITUATION:
39A. DO YOU:
39B. DO YOU HAVE STABLE
HOUSING AT PRESENT?
RENT
YES
NO
OWN
(If "No," complete Item 39C)
OTHER
40A. WHAT MODE OF TRANSPORTATION DO YOU USE?
PERSONAL
PUBLIC TRANSPORTATION
OTHER
40B. HOW FAR ARE YOU WILLING TO COMMUTE FOR WORK AND/OR
40C. DO YOU HAVE A VALID DRIVER'S LICENSE?
SCHOOL?
YES
NO
VA FORM 28-1902w, SEP 2015
Page 4
MISCELLANEOUS (CONTINUED)
41. ARE YOU WILLING TO RELOCATE FOR A JOB?
YES
NO
42. IF YOU HAVE HAD A HISTORY OF OR ARE CURRENTLY DEALING WITH LEGAL ISSUES, PLEASE SELECT AND DESCRIBE BELOW:
BANKRUPTCY
MISDEMEANOR
FELONY
PROBATION
PAROLE
OTHER
N/A
43. IF YOU HAVE HAD AND/OR PRESENTLY HAVE SUBSTANCE ABUSE ISSUES, PLEASE SELECT AND DESCRIBE BELOW:
ALCOHOL
DRUGS (Illicit)
DRUGS (Prescription)
OTHER
44. IF YOU HAVE A HISTORY OF OR ARE CURRENTLY IN ON-GOING TREATMENT(S) FOR SUBSTANCE ABUSE(S), PLEASE DESCRIBE BELOW:
45. DID ANYONE HELP YOU COMPLETE THIS FORM?
DATE COMPLETED
YES
NO
PROTECTION OF PRIVACY INFORMATION STATEMENT
(For use by counselees and rehabilitation program participants)
I have been informed and understand that the information requested in this and any later interviews is requested under the authorization of Title 38,
United States Code, 1.576, Veterans Benefits. This information is needed to assist in vocational and educational planning, to authorize my receipt of
rehabilitation services, to develop a record of my vocational progress, and to assure I obtain the best results from my rehabilitation program. I
understand that the information I provide will not be used for any other purpose and that my responses may be disclosed outside the VA only if the
disclosure is authorized under the Privacy Act of 1974, including the routine uses identified in VA system of records, 58VA21/22/28, Compensation,
Pension, Education, and Vocational Rehabilitation and Employment Records-VA, published in the Federal Register. Generally, disclosures under the
authority of a routine use will be made to develop my claim for vocational rehabilitation benefits under title 38, United States Code.
My giving the requested information is voluntary. I understand that the following results might occur if I do not give this information:
(1) I may not receive the maximum benefit either from counseling or from my education or rehabilitation program.
(2) If certain information is required before I may enter a VA program, my failure to give the information may result in my not receiving the
education or rehabilitation benefit for which I have applied.
(3) If I am in a program in which information on my progress is required, my failure to give this information may result in my not receiving
further benefits or services.
My failure to give this information will not have a negative effect on any other benefit to which I may be entitled.
I HEREBY CERTIFY THAT the information I have given above is true and correct to the best of my knowledge and belief.
SIGNATURE OF VETERAN
DATE SIGNED
SIGNATURE OF CASE MANAGER OR VOCATIONAL REHABILITATION COUNSELOR (VRC)
DATE SIGNED
VA FORM 28-1902w, SEP 2015
Page 5

Download VA Form 28-1902W Rehabilitation Needs Inventory (Rni)

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How to Fill out VA Form 28-1902w?

  1. Start the VA Form 28-1902w by providing your personal information. Enter your name, phone numbers, current address, email addresses, gender, marital status in Boxes 1-6. Enter your claim number in Box 7. Provide your social security number in Box 8. If you claim dependents, provide the number of dependents in Box 9. Enter your nicknames in Box 10, if applicable. Use Box 11 for emergency contact information.
  2. Enter your expectations from the VA programs in Box 12. Provide areas of professional interests of the veteran in Box 13. If you have ever participated in VA benefits programs, mark Box 14. Proceed to Boxes 14b and 14c in case of a positive reply.
  3. Thoroughly complete the employment section and attach a resume if you have one. Enter your civilian employment history in Box 15, starting from the most current position. Enter your military work history in Box 16, starting from the last assignment. Indicate the possibility of returning to work in a former occupation or for a former employer in Box 17.
  4. Enter a list of work skills that might be useful in the new job in Box 18. Indicate the periods of unemployment lasting three months or longer in Box 19.
  5. The next section is for providing information on education and training experience. Give your highest education level in Box 20. Enter information about your school in Boxes 21a-f. Indicate favorite and disliked school subjects in Boxes 22a-b.
  6. Specify whether you have any vocational certificates or licenses in Box 23a. In case of a positive reply, fill out Boxes 23b and 23c. If you have ever been diagnosed with a learning disability, indicate this in Box 24.
  7. The next section is for a description of disabilities. Describe any service-connected disabilities in Box 25. List any non-service-connected disabilities in Box 26. If any service-connected disabilities ever affected any areas of your work, indicate this in Box 27. If the mentioned disabilities are improving, mark Box 28. If they are stable, mark Box 29. If they are worsening, mark Box 30.
  8. Box 31 is for the specification which compensations or pensions you are receiving. If any claims are pending, mark Box 32.
  9. The next section is for a description of medical treatment. Describe any medical treatment you are receiving in Boxes 33a-d. If some medical needs are not met, disclose this in Box 34. If you are using any adaptive equipment, indicate it in Box 35. List other problems in Box 36. If there are any pending VA claims, indicate this in Box 37. Request information about other VA benefits and programs in Box 38.
  10. The last section is for providing miscellaneous information. Provide data about the housing and living situation in Boxes 39a-c and transportation details in Boxes 40a-c. If you are willing to relocate for a job, indicate it in Box 41. List any legal issues in Box 42. Use Box 43 for information about substance abuse. Use Box 44 for information on substance abuse treatment. If anyone helped you to fill the form out, indicate this in Box 45 and date the form.
  11. You and your case manager or vocational rehabilitation counselor should sign and date the form in boxes at the bottom of the form.
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