DVR-7G (Rev. 06/02/2014)
State of Colorado
Department of Human Services
Division of Vocational Rehabilitation
Please send report to:
11990 Grant Street, Suite 201
Northglenn, CO 80233
Phone: 303.866.2110
Fax: 303.866.2111
TTY: 303.866.2120
DISABILITY REPORT
(Information will be kept confidential)
STATEMENT TO EDUCATIONAL PROVIDER:
The Colorado Division of Vocational Rehabilitation helps people with physical and mental impairments obtain and retain employment. To
be eligible for DVR services the disability must create a barrier to employment. This report will be used to help determine this individual’s
eligibility for DVR services and to help develop their vocational plan. Please indicate how the limitations may affect the individual’s ability to
prepare for, obtain and/or maintain employment.
Last Name
APPLICANT/PATIENT IDENTIFICATION (To be completed by counselor)
First Name
Middle Name
Social Security Number
Address (Number and Street)
City
Applicant reports the following conditions and limitations:
State
Usual Occupation
REPORT OF FINDINGS:
Type of disability and areas that needed support in school:
Diagnostic Impressions (where applicable):
Axis I
Axis II
Axis III
Axis IV
Axis V
Medications (if any):
Strengths:
Provider’s Signature
Printed Name & Title
Date Signed
Psychologist’s Signature
Printed Name & Title
Date Signed
Other Signature
Printed Name & Title
Date Signed
Date of Birth
Zip Code
To be eligible for rehabilitation services, the disability must create an impediment to getting or keeping a job. The disability is permanent or expected to be
permanent if not treated. Please indicate how limitations in the following capacities affect or may affect this individual’s ability to obtain and/or maintain
employment.
Functional Capacities
Check if limited
Please check all that apply
Insufficient independent mobility to the degree necessary to
engage in work without services/accommodations
Inability to make use of public transportation
The physical, psychological or cognitive ability to move from
without instructions/services
place to place, inside and outside, including travel for
Requires accommodations for moving about at work settings
activities of daily living, training, or work. This includes
Other: ____________________________________________
limitations in mobility due to risks as a vulnerable individual
due to cognitive/psychological factors.
Problems getting from place to place
Difficulty getting around school/work
Poor fine motor skills
Motor Skills
Poor gross motor skills
Unable to perform tasks at a competitive pace
The capacity for purposeful movement and control of the
Other: ____________________________________________
body including control in coordination, of fine and gross
motor movements to accomplish specific tasks. For
employment this considers the capacity to perform work
tasks at an acceptable pace.
Hygiene causes problems at work/school
Self Care
Requires supervision or attendant care
Requires interventions to address medical needs
The ability to care for self and living environment (i.e.,
Does not present self appropriately for work/school
eating, toileting, grooming, dress, and money
Other: ____________________________________________
management) to participate in training or work. This
includes the management of any special medical and
safety needs. Limitations may occur because of physical,
cognitive, or emotional impairments.
Creates conflict with others-will hinder ability to work as part of
Interpersonal Skills
a group
On-going problems with establishing and maintaining positive
The ability to establish and maintain personal, family, and
working relationships
community relationships as it affects or is likely to affect
Due to disability-related characteristics, individual’s selfjob performance and security.
concept seriously limits ability to interact with others
Does not read social cues well-will interfere with
ability to interact with customers/co-workers
Lacks confidence when attempting new task-will
need extra support when starting a new job
Self-concept limits ability to interact with peer/coworkers
Has few friends/has difficulty with establishing relationships
Has difficulty maintaining relationships
Unable or unwilling to interact with others
Other: ____________________________________________
Unable to hear or understand spoken communications or
Communication
environmentally relevant sounds(e.g. Bells or high-pitched tones)
typically used in work environments
The ability to give and receive information including
Does not adequately see standard printed material or signage
hearing or understanding spoken communication and
Speech is not usable as an effective means of communication
sounds, speaking, seeing printed material or signage, and
in
the performance of job tasks
language skills sufficient for written or spoken work
Language skills are insufficient for written or spoken receptive
related communication. This does not include language
or expressive work-related communication
or cultural differences unrelated to disability.
Does not ask for help-will create issues on the job when unsure of
job tasks
Difficult to understand individual through spoken/written
communication (may struggle with job interviews)
Requires specialized & repetitive instructions on
the job to learn new job tasks
Has difficulty filling out applications and reading job announcements
Due to language and/or communication difficulties struggles in job
related communication
Other: ____________________________________________
Mobility:
Work Tolerance
The capacity to meet common or normal physical,
psychological, and environmental demands of work
including endurance, stamina, and consistent physical
or mental effort.
Work Skills
The capacity to learn and perform job tasks, remember
and concentrate sufficiently to retain performance of tasks
and the capacity to learn new or changed tasks. This
includes the speed and quality with which job tasks can
be performed for reasons other than limitation in motor
skills.
Frequent or extended absences from work for treatment of
recurring medical/psychological problems
Limited endurance in normal physical/psychological demands
Restricted to light duty or sedentary activities and occupations
Is typically adversely affected by environmental conditions in
the work place (i.e. heat, cold, fumes)
Unable to sustain mental or physical work efforts for more than
4 hours
May require special accommodations to meet physical/psychological
demands
Cannot perform at a competitive level without supportive services
Other: ____________________________________________
Needs time and specialized instruction to learn/process new
information
Memory skills are weak-needs written directions, lists and
visual cues when tasks are assigned
Inability to concentrate affects short-term memory
Reading, writing Low and/or Arithmetic skills: Grade
Level_______________________________________________
Limited in performing work tasks at a competitive level for
reasons other than motor skills
Difficulty concentrating with distractions & interruptions-has trouble
work as part of a group
Will need frequent breaks due to attention deficits
Would perform better with an active job that has many
changing duties
Need a clear routine, gets upset by sudden changes
Behavior typically incongruent with stated goals-unable to job seek
independently
Difficulty planning-unable to complete assigned tasks
Needs a lot of support and monitoring to follow through on
goals or tasks
Other: ____________________________________________
Frequently makes rash or unwise decisions that have negative
consequences
Needs extensive coaching or supervision to complete tasks or
The ability to plan, initiate, problem solve, organize, and
self-advocate
manage goal directed activities and behaviors
Behavior is typically in contradiction to preparing for, securing,
necessary for daily living and work.
retaining, or regaining employment
Due to limitations, places self or job at risk due to poor
decision-making, reasoning and/or judgment.
Distorts or refuses to accept responsibilities for vocational
limitations
Impulsive/reckless behavior
Refuses to accept responsibility for self actions
Unable or unwilling to identify solutions to work problems, needs
assistance and direction to solve problems
Other: ____________________________________________
Self Direction
RECOMMENDATIONS AND/OR ADDITIONAL INFORMATION
In your opinion, can this person engage in the following
occupation?
Yes
No
Reasons: