Form DR397A "Career Counseling and Information and Referral Form a - Verification" - California

What Is Form DR397A?

This is a legal form that was released by the California Department of Rehabilitation - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2018;
  • The latest edition provided by the California Department of Rehabilitation;
  • Easy to use and ready to print;
  • Available in Spanish;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DR397A by clicking the link below or browse more documents and templates provided by the California Department of Rehabilitation.

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Download Form DR397A "Career Counseling and Information and Referral Form a - Verification" - California

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STATE OF CALIFORNIA
DEPARTMENT OF REHABILITATION
Career Counseling and Information and Referral
Form A: Verification
DR 397A (Rev. 01/18)
Page 1 of 2
This is Me:
Last Name
First Name
Middle Name
Address
City
Zip Code
Conservator Name
Last 4 Digits of My SSN # Employment Start Date
(If Applicable)
This is Where I Work:
Employer Name
Employer Phone #
Employer Email
Employer Street Address
City
Zip Code
The Career Counseling and Information and Referral (CC&IR) Services I
Received Today are:
 Career counseling, including information about competitive integrated employment,
self advocacy, self-determination, available job supports, career exploration and
assessment, labor market information, and benefits planning.
 Information and referral, including information about federal and state programs and
local resources that offer employment-related services and supports designed to
help me further explore, experience, and attain jobs in the community.
For more information on the requirements for career counseling and information and referral services,
refer to Code of Federal Regulations, title 34, parts 397.1 through 397.50, at
https://ecfr.io/Title-
34/sp34.2.397.a
Proof of My Services Today:
This form proves that the Department of Rehabilitation (DOR) provided me with CC&IR
services on
(date).
___________________________________
DOR Staff Name (Print):
__________________________________
DOR Staff Signature:
Date:
_____________________________________
________________
Delivery Method: ☐Hand-delivered ☐Mailed ☐Faxed ☐Emailed ☐Other: ________
STATE OF CALIFORNIA
DEPARTMENT OF REHABILITATION
Career Counseling and Information and Referral
Form A: Verification
DR 397A (Rev. 01/18)
Page 1 of 2
This is Me:
Last Name
First Name
Middle Name
Address
City
Zip Code
Conservator Name
Last 4 Digits of My SSN # Employment Start Date
(If Applicable)
This is Where I Work:
Employer Name
Employer Phone #
Employer Email
Employer Street Address
City
Zip Code
The Career Counseling and Information and Referral (CC&IR) Services I
Received Today are:
 Career counseling, including information about competitive integrated employment,
self advocacy, self-determination, available job supports, career exploration and
assessment, labor market information, and benefits planning.
 Information and referral, including information about federal and state programs and
local resources that offer employment-related services and supports designed to
help me further explore, experience, and attain jobs in the community.
For more information on the requirements for career counseling and information and referral services,
refer to Code of Federal Regulations, title 34, parts 397.1 through 397.50, at
https://ecfr.io/Title-
34/sp34.2.397.a
Proof of My Services Today:
This form proves that the Department of Rehabilitation (DOR) provided me with CC&IR
services on
(date).
___________________________________
DOR Staff Name (Print):
__________________________________
DOR Staff Signature:
Date:
_____________________________________
________________
Delivery Method: ☐Hand-delivered ☐Mailed ☐Faxed ☐Emailed ☐Other: ________
STATE OF CALIFORNIA
DEPARTMENT OF REHABILITATION
Career Counseling and Information and Referral
Form A: Verification
DR 397A (Rev. 01/18)
Page 2 of 2
FORM A COMPLETION INSTRUCTIONS
1. Employee original form. Provide the original Form A to the employee. This form and the date
it is signed serve as documentation that the employee has received career counseling and
information and referral services from DOR.
2. Employer copy. Obtain a copy of the Form A from the employee. Note: DOR cannot make or
retain copies for the employer without employee’s written consent.
3. DOR copy. Retain a copy of the Form A for DOR records.
PRIVACY STATEMENT
The California Information Practices Act of 1977 (Civ. Code § 1798.17) and the Federal Privacy Act
(5 U.S.C. § 552a) require this notice be provided to individuals when collecting personal information.
The information requested on this form, including in some cases the Social Security Number, is
necessary to correctly identify the individual and provide his or her written consent to obtain or
release information to assist in the delivery of vocational rehabilitation services or release information
at the individual’s request (Welfare & Inst. Code §§ 19005, 19011, 29.U.S.C § 705(2)). Individuals
should not provide any personal information on this form that is not requested.
An individual has the right to revoke this authorization by providing written notice to the local
Department of Rehabilitation (DOR) office serving the individual. If an individual revokes the
authorization, it will not affect information already used or released before the DOR received the
individual’s written notice. The federal Health Insurance Portability and Accountability Act (HIPAA) (42
U.S.C. § 290dd-2) may not protect information after it is released or provided to agencies not covered
by that law. Even though the DOR is not subject to HIPAA, the DOR adheres to applicable federal
and state privacy laws. The DOR’s Privacy Policy is online at www.dor.ca.gov.
NOTICE TO INDIVIDUAL OR AGENCY RECEIVING OR OBTAINING INFORMATION
An individual has the right to inspect information maintained by the DOR about the individual, unless
otherwise prohibited or conditioned by law or regulation. For assistance accessing such information,
contact the DOR staff listed on the form.
Any personal information collected by the DOR is subject to the limitations in the California
Information Practices Act (Civ. Code § 1798 et seq.), Title 34 Code of Federal Regulations section
361.38, and California Code of Regulations, title 9, sections 7140 through 7143.5. The DOR may
release personal information in response to a court order, investigations in connection with law
enforcement, fraud, or abuse, subject to the limitations set forth in California Code of Regulations, title
9, section 7143.5 (34 C.F.R. § 361.38(e) (4) and (5)).
If information is RELEASED to an individual or agency with the informed, written consent of the
individual to whom the information pertains, the receiving individual or agency should be aware that
the information from the DOR is confidential. Federal regulation and state law and regulation prohibit
any further disclosure of this information without the informed, written consent of the individual to
whom this information pertains, unless otherwise permitted by law.
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