"Training and Adjustment Services Student Application" - Utah

Training and Adjustment Services Student Application is a legal document that was released by the Utah Department of Workforce Services - a government authority operating within Utah.

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TRAINING AND ADJUSTMENT SERVICES STUDENT APPLICATION
SERVICES FOR THE BLIND AND VISUALLY IMPAIRED
Part I. General Information
Date:
Birth Date:
Gender
Male ☐
Female ☐
Full Name:
Preferred Name:
Mailing Address:
City:
State:
Zip Code:
Permanent Address (if different):
City:
State:
Zip Code:
E-Mail Address:
Home Phone Number:
Cell Phone Number:
Utah Resident:
Height:
Weight:
Shoe Size:
Yes ☐
No ☐
Do you have an open Rehabilitation Case?
Yes
No ☐ Counselor’s Name:
Primary source of income: Employment, Self ☐
Employment, Spouse ☐
SSI ☐
SSDI ☐
Other ☐
Do you live alone, with family or other?
Alone ☐ Family ☐
Room Mate(s) ☐
Care Center ☐
Other ☐
Do you want to attend classes full or part time?
Part Time ☐
Full time ☐ Full-time and Stay in Apartments ☐
What month would you prefer to begin your training?
Cause of vision loss:
Stability of vision:
Stable at least 2 years ☐
Changing rapidly ☐
Changing Slowly ☐
Totally Blind ☐
Have you ever been convicted of a felony or misdemeanor crime? If yes, please explain below:
Yes ☐
No ☐
Explanation:
Emergency Contact Information
Contact Name:
Telephone Number:
Relationship to You:
Describe your primary reason for choosing to seek training at this time?
How were you referred to TAS? Rehab Counselor ☐ Doctor ☐
Organization ☐
Friend ☐
Other ☐
Name of referrer:
Telephone Number:
Address:
Have you attended (any) previous formal blindness skills training program?
When:
Yes ☐
No ☐
Name of Program:
City/State:
Utah State Office of Rehabilitation • A Division of the Department of Workforce Services
250 North 1950 West, Ste B Salt Lake City, Utah 84116-7902 • Telephone 801-323-4343
Relay Utah 711 • Spanish Relay Utah 1-888-346-3162 • Fax 801-323-4396 • usor.utah.gov • Equal Opportunity Employer/Programs
TRAINING AND ADJUSTMENT SERVICES STUDENT APPLICATION
SERVICES FOR THE BLIND AND VISUALLY IMPAIRED
Part I. General Information
Date:
Birth Date:
Gender
Male ☐
Female ☐
Full Name:
Preferred Name:
Mailing Address:
City:
State:
Zip Code:
Permanent Address (if different):
City:
State:
Zip Code:
E-Mail Address:
Home Phone Number:
Cell Phone Number:
Utah Resident:
Height:
Weight:
Shoe Size:
Yes ☐
No ☐
Do you have an open Rehabilitation Case?
Yes
No ☐ Counselor’s Name:
Primary source of income: Employment, Self ☐
Employment, Spouse ☐
SSI ☐
SSDI ☐
Other ☐
Do you live alone, with family or other?
Alone ☐ Family ☐
Room Mate(s) ☐
Care Center ☐
Other ☐
Do you want to attend classes full or part time?
Part Time ☐
Full time ☐ Full-time and Stay in Apartments ☐
What month would you prefer to begin your training?
Cause of vision loss:
Stability of vision:
Stable at least 2 years ☐
Changing rapidly ☐
Changing Slowly ☐
Totally Blind ☐
Have you ever been convicted of a felony or misdemeanor crime? If yes, please explain below:
Yes ☐
No ☐
Explanation:
Emergency Contact Information
Contact Name:
Telephone Number:
Relationship to You:
Describe your primary reason for choosing to seek training at this time?
How were you referred to TAS? Rehab Counselor ☐ Doctor ☐
Organization ☐
Friend ☐
Other ☐
Name of referrer:
Telephone Number:
Address:
Have you attended (any) previous formal blindness skills training program?
When:
Yes ☐
No ☐
Name of Program:
City/State:
Utah State Office of Rehabilitation • A Division of the Department of Workforce Services
250 North 1950 West, Ste B Salt Lake City, Utah 84116-7902 • Telephone 801-323-4343
Relay Utah 711 • Spanish Relay Utah 1-888-346-3162 • Fax 801-323-4396 • usor.utah.gov • Equal Opportunity Employer/Programs
TAS Application
Part II Educational Background
What level of education are you at currently? What certifications, diplomas, or college degrees have you earned?
High School-Not completed ☐
High School Graduate ☐
GED ☐
Certification ☐
Some College ☐
Associate Degree ☐
Bachelor’s Degree ☐
Master’s Degree☐
Doctorate Degree ☐
Other ☐
Where did you last attend High School?
Name of college or University you attended:
Major Course of Study:
Dates Attended:
From:
To:
Name of college or University you attended:
Major Course of Study:
Dates Attended:
From:
To:
Name of college or University you attended:
Major Course of Study:
Dates Attended:
From:
To:
Part III Employment Background
Provide the company name, your position, when you worked there, and why you no longer work at your last 3 jobs:
Company Name:
Position:
From:
To:
Reason for leaving:
Company Name:
Position:
From:
To:
Reason for leaving:
Company Name:
Position:
From:
To:
Reason for leaving:
Part IV Medical Background
The training program is a highly physical, mental and emotional learning experience. Please check all of the following
that apply to you, and describe any additional disabilities or concerns in detail where indicated. This will help us meet
your individual needs:
Diabetes: ☐ Type:
One ☐ Two
Insulin Dependent?
Neuropothy? Yes ☐
Yes ☐
No ☐
No ☐
Wear hearing aids?
Do you use sign Language?
Hearing Loss: ☐
Right Ear ☐
Yes ☐
Yes ☐
No ☐
Do you read lips?
Left Ear
No ☐
Yes ☐
No ☐
Learning/Cognitive Processing: ☐
Traumatic Brain Injury (TBI): ☐
ADHD: ☐
Stroke: ☐
Demensia: ☐
Sleep Disorders:
Mental Illness: ☐ Seizures: ☐ Blood Pressure: ☐
Asthma: ☐
Respitory Problem: ☐
Alergies: ☐ Specify:
Speech Disorder: ☐
Orthopedic/Back Problems: ☐
Kidney Problems: ☐
Past Alcohol/Substance Abuse: ☐
Psychological/Emotional Issues: ☐
Depression: ☐
Anxiety: ☐
Behavior: ☐
Other: ☐
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TAS Application
Please use this space to provide additional details regarding any medical concerns you have:
Are you familiar with safety skills such as accessing emergency services, understanding and complying with emergency
evacuation procedures, managing first aid care on self, etc.? Yes☐ No ☐
Name(s) of Medical Practitioner (Doctor):
Telephone Number:
Preferred Hospital Name:
Telephone Number:
Medical Insurance Provider(s):
Membership Number(s):
Telephone Number:
Are you able to manage your own health care and self-administer medications?
Yes ☐
No ☐
Current List of Medications continued:
Dosage:
Frequency:
Part V Additional Information And Requirements
What are your greatest strengths?
What are your greatest weaknesses?
What do you want to accomplish from this training experience?
What goals do you have for your future?
TAS requires a current (within two years) visual acuity (eye report) from an ophthalmologist for verification of legal
blindness. TAS also requires a valid Utah Identification card.
I understand this is a non-visual training program and I will be required to wear training shades in order to keep a full-
time or part-time status.
Please sign your name to indicate that you are willing to abide by this requirement. Electronic signature is accepted.
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TAS Application
Student Signature: ___________________________________________________________________________________
Visit our website at https://www.usor.utah.gov/dsbvi
Completed applications can be emailed to jodiduke@utah.gov, faxed to 801-323-4396,
or mailed to 250 North 1950 West, Suite B, Salt Lake City, Utah 84116.
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