Form DR397R "Section 511 Career Counseling and Information and Referral (Cc&ir) Request for Initial Cc&ir Services" - California

What Is Form DR397R?

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, 2021;
  • The latest edition provided by the California Department of Rehabilitation;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DR397R by clicking the link below or browse more documents and templates provided by the California Department of Rehabilitation.

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Download Form DR397R "Section 511 Career Counseling and Information and Referral (Cc&ir) Request for Initial Cc&ir Services" - California

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STATE OF CALIFORNIA
DEPARTMENT OF REHABILITATION
Section 511 Career Counseling and Information and Referral (CC&IR)
Request for Initial CC&IR Services
DR397R (New 01/21)
Page 1 of 4
14(c) Worker Name/CC&IR Recipient
Preferred Name
Street Address, City, and Zip Code
Phone Number
Date of Birth
Email Address
Gender
Male
Female
Decline to State
What is your race and ethnicity? (check all that may apply)
American Indian/Alaskan Native
Asian Indian
Black or African American
Cambodian
Chinese
Filipino
Guamanian or Chamorro
Hawaiian
Hispanic or Latino
Japanese
Korean
Laotian
Other Asian
Other Pacific Islander
Samoan
Vietnamese
White
Decline to State
Need an Interpreter?
Primary Source of Support (select one)
Yes
All Other Sources
Personal Income
Decline to State
Language ________________
Family and Friends
Public Support (SSI, SSDI, TANF, etc.)
Regional Center Name
UCI#
Legal Guardian/Conservator Name
Relationship
Email Address
Phone Number
14(
) W
/CC&IR R
C
R
S
R
I
C
ORKER
ECIPIENT
ONSENT FOR
ELEASE AND
HARING OF
EQUESTED
NFORMATION
I give permission to the 14(c) Employer and the Department of Rehabilitation to share information
relevant to my CC&IR services with each other, and with the Regional Center listed above as
appropriate.
14(c) Worker/CC&IR Recipient Signature
Print Name
Date
STATE OF CALIFORNIA
DEPARTMENT OF REHABILITATION
Section 511 Career Counseling and Information and Referral (CC&IR)
Request for Initial CC&IR Services
DR397R (New 01/21)
Page 1 of 4
14(c) Worker Name/CC&IR Recipient
Preferred Name
Street Address, City, and Zip Code
Phone Number
Date of Birth
Email Address
Gender
Male
Female
Decline to State
What is your race and ethnicity? (check all that may apply)
American Indian/Alaskan Native
Asian Indian
Black or African American
Cambodian
Chinese
Filipino
Guamanian or Chamorro
Hawaiian
Hispanic or Latino
Japanese
Korean
Laotian
Other Asian
Other Pacific Islander
Samoan
Vietnamese
White
Decline to State
Need an Interpreter?
Primary Source of Support (select one)
Yes
All Other Sources
Personal Income
Decline to State
Language ________________
Family and Friends
Public Support (SSI, SSDI, TANF, etc.)
Regional Center Name
UCI#
Legal Guardian/Conservator Name
Relationship
Email Address
Phone Number
14(
) W
/CC&IR R
C
R
S
R
I
C
ORKER
ECIPIENT
ONSENT FOR
ELEASE AND
HARING OF
EQUESTED
NFORMATION
I give permission to the 14(c) Employer and the Department of Rehabilitation to share information
relevant to my CC&IR services with each other, and with the Regional Center listed above as
appropriate.
14(c) Worker/CC&IR Recipient Signature
Print Name
Date
STATE OF CALIFORNIA
DEPARTMENT OF REHABILITATION
Section 511 Career Counseling and Information and Referral (CC&IR)
Request for Initial CC&IR Services
DR397R (New 01/21)
Page 2 of 3
L
G
/C
C
[I
R
]
EGAL
UARDIAN
ONSERVATOR
ONSENT
F
EQUIRED
I declare that I am the legal guardian/conservator of the 14(c) Worker/CC&IR Recipient named above and
I have the legal right to authorize this consent.
Authorized Signature
Print Name
Date
To be Completed by 14(c) Certificate Holder/Employer Representative:
14(c) Certificate Holder (Employer) Name of Record
14(c) Employer Work Site Name (If different)
Street Address, City, Zip Code
14(c) Employer Email Address
14(c) Employer Phone
14(c) Worker/CC&IR Recipient
DOL 14(c) Worker/CC&IR Recipient Primary Impairment
Wage Earning Start Date _____________
Intellectual/Developmental
Substance Abuse
Average Hourly Wage _______________
Psychiatric
Neuromuscular
Work Setting
Visual Impairment
Age Related
Sheltered Workshop
Hearing Impairment
Group Placement
Other (Specify) ________________________________
Authorized 14(c) Employer Representative Signature
Print Name/Title
Date
FORM PURPOSE AND COMPLETION INSTRUCTIONS
This form is intended for use by the 14(c) Employer Representative in collaboration with the 14(c) Worker
to notify the Department of Rehabilitation (DOR) of the request for Career Counseling and Information and
Referral (CC&IR) services for an individual newly hired for subminimum wage employment. Pursuant to
Workforce Innovation and Opportunity Act Section 511
34 CFR
397, the DOR must provide, at certain
prescribed intervals for the duration of such employment, career counseling and information and referral
services, designed to promote opportunities for competitive integrated employment, to individuals with
disabilities, regardless of age, who are known to be employed at subminimum wage. In support of the
Home and Community-Based Services Final Rule, individuals working in a non-integrated employment
setting may also request CC&IR services to learn about their options and services to pursue competitive
integrated employment.
1. 14(c) Worker/CC&IR Recipient: Complete the top portion of this form. This information will be used
to:
a. Identify and record the appropriate Career Counseling and Information and Referral (CC&IR)
services that will support the individual’s goals.
STATE OF CALIFORNIA
DEPARTMENT OF REHABILITATION
Section 511 Career Counseling and Information and Referral (CC&IR)
Request for Initial CC&IR Services
DR397R (New 01/21)
Page 3 of 3
b. Partner with the 14(c) Employer and Regional Center regarding the coordination of potential
employment and support services, as appropriate.
c. Conduct aggregate analysis of demographic data trends that support quality services.
2. 14(c) Worker/CC&IR Recipient and Guardian Conservator, as appropriate: Review the information
provided for accuracy, and sign to designate approval for the 14(c) Employer to submit the form to the
DOR Achieving Community Employment (ACE) Team.
3. 14(c) Employer Representative:
a. Review the information provided; and, complete the bottom portion and sign the form.
b. Submit completed, signed form to DOR ACE Team 511 CCIR@dor.ca.gov.
c. Retain a copy for your records.
4. DOR ACE Team: Upon receipt of this form, the ACE Team will:
a. Assign the new 14(c) Worker/CC&IR Recipient to the regional ACE Rehabilitation Counselor
and open a DOR record of services to document the CC&IR services needed and provided.
b. Schedule person-centered CC&IR services that meet the individual’s needs and employment
related interests.
PRIVACY STATEMENT
An individual, with the Legal Guardian or Conservator if applicable, has the right to inspect information
maintained by DOR about the individual, unless otherwise prohibited or conditioned by law or regulation.
For assistance accessing such information, contact DOR.
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 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.
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)).
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