Blank VBA VA 28-1902w Template

OMB Approved No. 2900-0092

Respondent Burden: 45 Minutes

Expiration Date: 11/30/2027

INFORMATION FOR VETERAN READINESS AND

EMPLOYMENT ENTITLEMENT DETERMINATION

INSTRUCTIONS: This form is used during the comprehensive initial evaluation to assist with gathering information for an Entitlement Determination. For more information, contact us at https://ask.va.gov or call us toll-free at 1-800-827-1000. If you use a Telecommunications Device for the Deaf (TDD), the Federal relay number is 711. VA forms are available at www.va.gov/vaforms.

During the initial evaluation, the Vocational Rehabilitation Counselor (VRC) will review the form with the claimant to obtain additional and/or missing information necessary to determine the claimant's entitlement to Chapter 31 benefits. The VRC will use their counseling skills while utilizing this form to assist with making an entitlement determination. The VRC will review and discuss the responses from the claimant during the initial evaluation to address:

•Development and analysis of information necessary to obtain a general understanding of the whole individual.

•Evaluation of claimant's capacity for suitable employment and/or independence in daily living, in accordance with 38 CFR § 21.50.

•Entitlement determination to VR&E Program, including Employment Handicap (EH) and Serious Handicap (SEH) determination, in accordance with 38 CFR § 21.51 and § 21.52.

•Assess the following factors as part of the initial evaluation:

(1)Determination of the effect(s) of claimant's Service-Connected Disabilities (SCD) and Non-Service-Connected Disabilities (NSCD) condition(s) on obtaining and maintaining employment, and on independence in daily living;

(2)The claimant's physical and mental capabilities that may affect employability and ability to function independently in daily living activities in family and community;

(3)The claimant's abilities, aptitudes, and interests;

(4)The claimant's personal history and current circumstances (including educational and training achievements, employment record, developmental and related vocationally significant factors, and family and community adjustment); and

(5)Other factors that may affect the claimant's employability.

•Identification of barriers that impact claimant's employability.

CLAIMANT'S INFORMATION

CLAIMANT'S NAME (First, Middle Initial, Last)

SECTION I: VERIFICATION OF CLAIMANT'S CONTACT INFORMATION

(Please verify the claimant's contact information. If the claimant's contact information has changed or is different, please

advise the claimant to update their contact information and/or marital status on VA.gov profile).

SECTION II: REVIEW OF CLAIMANT'S CIVILIAN EMPLOYMENT HISTORY

(If the claimant provides their resume, it is not necessary to duplicate information in Items 1-9. However, the civilian employment (including self-employment) history must be reviewed and discussed to identify any difficulties with job duties, obtaining and maintaining employment, salary, full time, part-time, and reasons why claimant left job positions).

2.IF THE CLAIMANT IS UNEMPLOYED, HOW LONG HAS THE CLAIMANT BEEN UNEMPLOYED?

3.WHAT DID THE CLAIMANT DO DURING THE PERIOD OF UNEMPLOYMENT?

SECTION II: REVIEW OF CLAIMANT'S CIVILIAN EMPLOYMENT HISTORY (Continued)

(If the claimant provides their resume, it is not necessary to duplicate information in Items 1-9. However, the civilian employment (including self-employment) history must be reviewed and discussed to identify any difficulties with job duties, obtaining and maintaining employment, salary, full time, part-time, and reasons why claimant left job positions).

4. JOB TITLE:

NAME OF EMPLOYER: DATES OF EMPLOYMENT:

FULL-TIME PART-TIME AVERAGE GROSS MONTHLY SALARY: PROVIDE A DESCRIPTION OF JOB DUTIES IN DETAIL:

DO THE JOB DUTIES AGGRAVATE THE CLAIMANT'S SERVICE-CONNECTED DISABILITIES? (If "Yes," how?)

WHAT IS THE CLAIMANT'S REASON FOR LEAVING EMPLOYMENT? (e.g. resigned, fired, hired for another job)

5. JOB TITLE:

NAME OF EMPLOYER: DATES OF EMPLOYMENT:

FULL-TIME PART-TIME AVERAGE GROSS MONTHLY SALARY: PROVIDE A DESCRIPTION OF JOB DUTIES IN DETAIL:

DO THE JOB DUTIES AGGRAVATE THE CLAIMANT'S SERVICE-CONNECTED DISABILITIES? (If "Yes," how?)

WHAT IS THE CLAIMANT'S REASON FOR LEAVING EMPLOYMENT? (e.g. resigned, fired, hired for another job)

6. JOB TITLE:

NAME OF EMPLOYER: DATES OF EMPLOYMENT:

FULL-TIME PART-TIME AVERAGE GROSS MONTHLY SALARY: PROVIDE A DESCRIPTION OF JOB DUTIES IN DETAIL:

SECTION II: REVIEW OF CLAIMANT'S CIVILIAN EMPLOYMENT HISTORY (Continued)

(If the claimant provides their resume, it is not necessary to duplicate information in Items 1-9. However, the civilian employment (including self-employment) history must be reviewed and discussed to identify any difficulties with job duties, obtaining and maintaining employment, salary, full time, part-time, and reasons why claimant left job positions).

DO THE JOB DUTIES AGGRAVATE THE CLAIMANT'S SERVICE-CONNECTED DISABILITIES? (If "Yes," how?)

WHAT IS THE CLAIMANT'S REASON FOR LEAVING EMPLOYMENT? (e.g. resigned, fired, hired for another job)

7. JOB TITLE:

NAME OF EMPLOYER: DATES OF EMPLOYMENT:

FULL-TIME PART-TIME AVERAGE GROSS MONTHLY SALARY: PROVIDE A DESCRIPTION OF JOB DUTIES IN DETAIL:

DO THE JOB DUTIES AGGRAVATE THE CLAIMANT'S SERVICE-CONNECTED DISABILITIES? (If "Yes," how?)

WHAT IS THE CLAIMANT'S REASON FOR LEAVING EMPLOYMENT? (e.g. resigned, fired, hired for another job)

8. JOB TITLE:

NAME OF EMPLOYER: DATES OF EMPLOYMENT:

FULL-TIME PART-TIME AVERAGE GROSS MONTHLY SALARY: PROVIDE A DESCRIPTION OF JOB DUTIES IN DETAIL:

DO THE JOB DUTIES AGGRAVATE THE CLAIMANT'S SERVICE-CONNECTED DISABILITIES? (If "Yes," how?)

WHAT IS THE CLAIMANT'S REASON FOR LEAVING EMPLOYMENT? (e.g. resigned, fired, hired for another job)

SECTION II: REVIEW OF CLAIMANT'S CIVILIAN EMPLOYMENT HISTORY (Continued)

(If the claimant provides their resume, it is not necessary to duplicate information in Items 1-9. However, the civilian employment (including self-employment) history must be reviewed and discussed to identify any difficulties with job duties, obtaining and maintaining employment, salary, full time, part-time, and reasons why claimant left job positions).

9.HAS THE CLAIMANT EVER HAD DIFFICULTY WITH ANY OF THE FOLLOWING ITEM(S) DUE TO THEIR SCD(s)? (If "Yes," please describe in detail)

CO-WORKER RELATIONS:

JOB PERFORMANCE:

JOB OPPORTUNITIES:

JOB SATISFACTION:

MANAGER RELATIONS:

MISSED TIME AT WORK:

OTHERS:

SECTION III: REVIEW OF CLAIMANT'S MILITARY EMPLOYMENT HISTORY

(If the claimant provides their DD-214 or military records, it is not necessary to duplicate information in Items 10-13. However, the military employment history must be discussed to identify any difficulties with job duties, obtaining and maintaining employment, salary, full time, part-time, and reasons why claimant is unable to perform the job positions.)

CLAIMANT PROVIDED DD-214 OR MILITARY RECORDS (Please complete only fields not on DD-214 or military records)

CLAIMANT DID NOT PROVIDE DD-214 OR MILITARY RECORDS (Please complete section below)

10.LIST CLAIMANT'S MILITARY ENLISTMENT HISTORY

11.JOB TITLE OR MILITARY OCCUPATIONAL SPECIALTY

12A NAME OF BRANCH OF SERVICE

SELECTED SERVICE (Note: Members or former members of the Selected Reserve (Army, Air Force, Coast Guard, Marine Corps, Naval Reserve, Air National Guard, or Army National Guard) who served at least one enlistment or, in the case of an officer, the period of initial obligation, or were discharged for disability incurred or aggravated in line of duty.)

13A NAME OF BRANCH OF SERVICE (Please select if the claimant served more than one term of service and/or more than one branch of service.)

SELECTED SERVICE (Note: Members or former members of the Selected Reserve (Army, Air Force, Coast Guard, Marine Corps, Naval Reserve, Air National Guard, or Army National Guard) who served at least one enlistment or, in the case of an officer, the period of initial obligation, or were discharged for disability incurred or aggravated in line of duty.)

SECTION IV: REVIEW OF CLAIMANT'S LEGAL HISTORY

14.IF THE CLAIMANT HAS A HISTORY OF OR IS CURRENTLY DEALING WITH LEGAL ISSUES, SELECT ITEM(S) THAT APPLY AND DESCRIBE BELOW

BANKRUPTCY (In the last seven years):

MISDEMEANOR:

FELONY:

PROBATION:

PAROLE:

OTHER:

NOT APPLICABLE

SECTION V: REVIEW OF CLAIMANT'S SUBSTANCE ABUSE HISTORY

15.IF THE CLAIMANT HAS A HISTORY OF OR IS CURRENTLY DEALING WITH SUBSTANCE ABUSE ISSUES, SELECT ITEM(S) THAT APPLY AND DESCRIBE BELOW

ALCOHOL:

ILLEGAL DRUGS:

PRESCRIPTION DRUGS:

OTHER:

NOT APPLICABLE

IF THE CLAIMANT HAD A HISTORY OF OR IS CURRENTLY RECEIVING ONGOING TREATMENT(S) FOR SUBSTANCE ABUSE, DESCRIBE TREATMENT PROGRESS INCLUDING DATE(S) AND LOCATION(S) BELOW.

SECTION VI: REVIEW OF CLAIMANT'S EDUCATION/TRAINING HISTORY

(If the claimant provided academic or training transcripts, certifications and/or licenses,

please review their educational and/or training history.)

CLAIMANT PROVIDED TRANSCRIPTS, CERTIFICATIONS, AND/OR LICENSES (Do not need to complete all fields in this section.)

CLAIMANT DID NOT PROVIDE TRANSCRIPTS/CERTIFICATIONS, AND/OR LICENSES (Please complete section below)

17.IF CLAIMANT HAS EDUCATION BEYOND HIGH SCHOOL, WHAT WAS THE FIELD OF STUDY (Degree Major), IF APPLICABLE?

18.IF CLAIMANT HAS CERTIFICATION(S) OR LICENSES (e.g. Apprenticeship, Journeyman License, Commercial Driver's License (CDL), PLEASE LIST IF APPLICABLE.

SECTION VII: REVIEW OF CLAIMANT'S SERVICE-CONNECTED AND NON-SERVICE-CONNECTED DISABILITIES

(Discuss how the claimant's disabilities impact their ability to obtain and maintain employment.)

19. LIST THE CLAIMANT'S SERVICE-CONNECTED DISABILITIES AND IMPAIRMENTS.

SECTION VII: REVIEW OF CLAIMANT'S SERVICE-CONNECTED AND NON-SERVICE-CONNECTED DISABILITIES (Continued)

(Discuss how the claimant's disabilities impact their ability to obtain and maintain employment.)

20.HAS THE CLAIMANT FILED A CLAIM OR IS CLAIMANT RECEIVING INDIVIDUAL UNEMPLOYABILITY (IU) OR TOTAL DISABILITY BASED ON INDIVIDUAL UNEMPLOYABILITY (TDIU), (If "Yes," discuss in detail)

NOTE: VRC must review for the severity of claimant's SCDs, feasibility, and potential independent living needs.

21.DOES THE CLAIMANT HAVE A VALID DRIVER"S LICENSE? (If "No," please explain reason for not having a valid driver's license)

22. NAME OF MEDICAL TREATMENT FACILITIES THE CLAIMANT IS ATTENDING.

23. HOW OFTEN IS THE CLAIMANT SEEN FOR TREATMENT?

SECTION VIII: MISCELLANEOUS INFORMATION

(While the following information is not relevant to the entitlement determination, these

questions can assist with referrals, resources, and addressing claimant's needs.)

27. CHECK ITEM(S) THAT APPLY IF CLAIMANT IS RECEIVING OR HAS APPLIED FOR BENEFITS BELOW:

SECTION IX: COMMENTS

28.OTHER RELEVANT INFORMATION OR ADDITIONAL COMMENTS (Additional information provided during the initial evaluation that is relevant to the entitlement determination)

PRIVACY ACT INFORMATION: The responses you submit are considered confidential (38 U.S.C. 5701). Your obligation to respond is required in order to obtain benefits. 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., civil or criminal law enforcement, congressional communications, epidemiological or research studies, the collection of money owed to the United States, litigation in which the United States is a party or has an interest, the administration of VA programs and delivery of VA benefits, verification of identity and status, and personnel administration) as identified in the VA system of records, 58VA21/22/28, Compensation, Pension, Education, and Veteran Readiness and Employment Records - VA, published in the Federal Register. Information that you furnish may be utilized in computer matching programs with other Federal or State agencies for the purpose of determining your eligibility to receive VA benefits, as well as to collect any amount owed to the United States by virtue of your participation in any benefit program administered by the Department of Veterans Affairs.

RESPONDENT BURDEN: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is 2900-0092, and it expires November 30, 2027. Public reporting burden for this collection of information is estimated to average 45 minutes per respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate and any other aspect of this collection of information, including suggestions for reducing the burden, to VA Reports Clearance Officer at [email protected]. Please refer to OMB Control No. 2900-0092 in any correspondence. Do not send your completed VA Form 28-1902w to this email address.