VESID / Current Provider Information / Vocational Rehabilitation / Unified Contract Services

UCS Services Report Forms

November 18, 2009: Please replace any forms downloaded prior to November 18, 2009 with the newly reivsed forms below.

Entry Services

1. Cover Sheet – 118X or 117X
   Form: VES-118X and VES-117X (, 98KB, 1pg)
2. Orientation Provider Report
   Form: VES-O (, 95KB, 1pg)
3. Orientation Attendance Sheet
   Form: VES-OA (, 92KB, 1pg)
4. VESID Orientation (Consumer Survey)
   Form: VES-OS (, 92KB, 1pg)
5. Application Information Sheet
   Form: VES-AIS ( , 89KB, 1pg)

Job Placement Services

1. Level I
   1. Coaching Supports for Employment – 959X
      Coaching Supports for Employment - Deaf Service – 563X
      Form: VES-959X and VES-563X (, 100KB, 1pg)
2. Level II
   1. Direct Placement Intake - Tier 1 – 921X
      Form: VES-921X (, 95KB, 1pg)
   2. Job Placement Plan
      Job Seeking and Job Development Services - Tier 2 – 929X
      Job Seeking and Job Development Services (Deaf Service) - Tier 2 – 935X
      Form: VES-929X and VES-935X (, 99KB, 1pg)
   3. Job Placement - Tier 3 - 931X
      Job Placement (Deaf Service) - Tier 3 – 936X
      Form: VES-931X and VES-936X (, 100KB, 1pg)
   4. Job Retention Services - Tier 4 – 932X
      Job Retention Services (Deaf Service) - Tier 4 – 937X
      Form: VES-932X and VES-937X (, 104KB, 2pgs)
   5. Placement Activity Monthly Report
      Job Seeking and Job Development Services - Tier 2 – 929X
      Job Seeking and Job Development Services (Deaf Service) - Tier 2 – 935X
      Job Placement - Tier 3 – 931X
      Job Placement (Deaf Service) - Tier 3 – 936X
      Form: VES-MR (, 97KB, 2pgs)

Adjunct Services

1. Level I
   1. Work & Benefits Community Information Session, Provider Report Form
      Form: VES-BEN 1 (, 95KB, 1pg)
   2. Work & Benefits Community Information Session (Consumer Survey)
      Form: VES-BEN 2 (, 91KB, 1pg)
   3. Work & Benefits Community Information Session, Attendance Sheet
      Form: VES-BEN 3 (, 92KB, 1pg)
2. Level II
   1. Benefits Advisement Checklist
      Benefits Advisement - Short Term – 175X
      Form: VES-175X (, 116KB, 3pgs)
3. Level III
   1. Benefits Advisement - Long Term – 176X(I) and 176X(F)
      Form: VES-176X(I) and 176X(F) (, 96KB, 1pg)
4. Mobility Services
   Travel Competency Form – Mobility Training - MS
   Time Sheet for Mobility Training – MST
   Form: VES-MS and VES-MST ( , 103KB, 2pgs)
5. Coaching Supports – 790X
   Coaching Supports – Deaf Service – 791X
   (For Postsecondary Education, Internship, or Other Activities In Pursuit of Employment Goals)
   Form: VES-790X and VES-791X (, 96KB, 2pgs)

List of Forms without Description:

• Form: VES-118X and VES-117X (, 98KB, 1pg)
• Form: VES-O (, 95KB, 1pg)
• Form: VES-OA (, 92KB, 1pg)
• Form: VES-OS (, 92KB, 1pg)
• Form: VES-AIS ( , 89KB, 1pg)
• Form: VES-959X and VES-563X (, 100KB, 1pg)
• Form: VES-921X (, 95KB, 1pg)
• Form: VES-929X and VES-935X (, 99KB, 1pg)
• Form: VES-931X and VES-936X (, 100KB, 1pg)
• Form: VES-932X and VES-937X (, 104KB, 2pgs)
• Form: VES-MR (, 97KB, 2pgs)
• Form: VES-BEN 1 (, 95KB, 1pg)
• Form: VES-BEN 2 (, 91KB, 1pg)
• Form: VES-BEN 3 (, 92KB, 1pg)
• Form: VES-175X (, 116KB, 3pgs)
• Form: VES-176X(I) and 176X(F) (, 96KB, 1pg)
• Form: VES-MS and VES-MST ( , 103KB, 2pgs)
• Form: VES-790X and VES-791X (, 96KB, 2pgs)

Additional Resources

Quick Links to NYS Office of State Comptroller Voucher Forms

1. AC 92 Standard Voucher (Word Template) - (AC 92 pdf)
2. NYS Office of State Comptroller AC 92 Instructions
   
   
3. AC 93 Continuation Sheet (Word Template) - (AC 93 pdf)
4. NYS Office of State Comptroller AC 93 Instructions

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