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Family and Social Services Administration

DDRS Home > Information for Consumers > Forms Forms

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*The following forms can be completed online and then printed.

**These forms cannot be filled in online. They may be printed out and filled in by hand.

DDRS Form

Authorization for Disclosure of Personal and Health Information form (HIPAA)

 

Bureau of Developmental Disabilities Services

Application for Developmental Disabilities Services (State Form 55068)

Confirmation of Diagnosis 54727 (Revised 450B)
Please use this form to comply with Federal and State regulation that requires a physician's confirmation that the individual's developmental disability/intellectual disability (DD/ID) condition manifested before the age of 22.

Individual Support Plan (ISP) Forms

PASARR Level I - Identification Evaluation Criteria - Certification by Physician for Long-Term Care Services 45277*
Completed by the physician, PAS Agency assessor, hospital discharge planner or the nursing facility. The purpose is for the federally required PASRR screening for all individuals requesting admission to a nursing facility, to determine if the individuals might possibly have a mentally illness or a developmental/intellectual disability (DD/ID)and therefore require further assessment (Level II) to determine if they can be admitted to the facility. This form can also be used to screen residents in a nursing facility who have undergone a change in condition and may require a PASRR Level II assessment to determine if they can remain in the facility. NOTE: This form is generally known as the PASRR Level I, and is also known as the form 450B/PASRR2A, Sections IV and V, Part A.

Bureau of Quality Improvement (BQIS)

Post-Transition Quality Assurance Checklist 51681 (PDF document)*

Post-Transition Quality Assurance Checklist 51682 (PDF document)*

Pre-Transition Quality Assurance Checklist 51683 (PDF document)*

Pre-Transition Quality Assurance Checklist 51684 (PDF document)*

Provider Standards Agency Survey 51678 (PDF document)*

Residential Services and Supports Survey 51679 (PDF document)*

State Form 51685  Notification of Individual's Death **

Community Vocational/Habilitation Survey 51680**

 

Deaf and Hard of Hearing Services

Interpreter Service Program Communication Request  
Enables DHHS to ascertain that the interpreting services are within the specific guidelines when they were provided at state agencies or state functions. Statistics are compiled from this form on who was being served, which state agencies utilize this service, number of hours, etc. The quality of interpreting services can be measured using the information provided.

Indiana Interpreter Certificate Application 49978
Used to determine whether applicant meets criteria to be an IIC interpreter.

Indiana Interpreter Certificate Application for Renewal

Indiana Interpreter Certificate or Identification Replacement Card Application

Indiana Interpreter Certificate CEU

DHHS CEU Sponsorship Approval 51381

Block Grant Plan of Action 54038

Block Grant Daily Log 54037

Block Grant Monthly Report 48203
Enables DHHS to ascertain that the case management services are within the specified federal guidelines. Statistics are compiled from this form on who was being served, number of hours, etc. The quality of case management services can be measured using this information.

Social Services Block Grant (SSBG) Application and Services Registration 49452
Enables DHHS staff to keep statistics on the number of people we serve along with other information such as age, gender, sex, and so forth.

Vocational Rehabilitation Services (VRS)

Commission on Rehabilitation Counselor Certification - Verification of Attendance 26460**
Used to verify attendance by rehabilitation counselors at CEU approved training conferences, workshops, seminars, and other educational programs so they may earn continuing education credits required to keep their Certified Rehabilitation Counselor certificates. CRC counselors are required to accumulate a specific number of CEU's each year in order to qualify to work as CRC counselors.

Commission on Rehabilitation Services Customer Satisfaction Survey 46098**
All individuals who have completed their VRS program are given a Customer Satisfaction Survey form to respond to questions about the quality and effectiveness of VRS services provided to them. This information is used to evaluate the way VRS services can be improved or made more effective for people with disabilities.

Commission on Rehabilitation Services - Satisfaction Survey - Large Print Version 49823**
All individuals with visual impairments who have completed their VRS service programs are given a large print Customer Satisfaction Survey form to respond to questions about the quality and effectiveness of VRS services provided to them. This information is reviewed to determine how VRS services to visually impaired individuals may be improved.

Commission on Rehabilitation Services - Satisfaction Survey for Customers with Pre-Lingual Deafness 49603**
Pre-lingually deaf individuals who have completed their VRS service program are given a Customer Satisfaction Survey form that asks questions about VRS services provided to them in a simplified language format. This information is used to evaluate the manner VRS services are provided to deaf individuals to make the VRS program more responsive to their vocational and communication needs.

DDRS Referral and Application 10057**
Used when an individual applies for services from VRS or the Bureau of Developmental Disabilities Services. The VRS or the BDDS counselor obtains background information about the individual to assist in an evaluation of the individual's eligibility for services for either division. This questionnaire is given to individuals who apply for VRS services. The VRS customer fills out this form on his own.

Financial Aid Communications 41378**
Used to provide the VRS counselor with information from college financial aid office as to the amount of financial assistance VRS can provide to the student. This form is utilized each academic year by the VRS counselor for all VRS post secondary student/customers.

Blind & Visually Impaired Services

Confidential Report of Blindness or Visual Impairment 48126**

Employment Questionnaire 04677**
This questionnaire is given to individuals who apply for VRS services. Some individuals are still working when they apply for VRS services, so it is necessary to provide the VRS counselor with the details about his or her job in order to help determine what services may be needed to assist the individual in retaining employment or obtaining a new job. The VRS customer fills out his form on their own.

Referral for Services for the Blind and Visually Impaired 46206**
This is the referral form for BVIS services and programs.

Information Required in an Emergency 46213**
Used for blind individuals receiving services at the Bosma Center for the Blind. In case of injury or illness while at the Center, the caseworker would fill out this form so the blind individual would receive emergency medical care. This form is used to authorize the BVIS to obtain emergency medical and/or hospital services.
 

Additional Forms

Indiana Appointment for Health Care Representative**
Used appoint an individual as a health care representative.

ISDH - Advance Directives - Your Right To Decide  **
Brochure is to inform you of ways that you can direct your medical care and treatment in the event that you are unable to communicate for yourself.

Life Prolonging Procedures Declaration**
Official request form for the use of life prolonging procedures that would extend one’s life

Living Will Declaration **
Official request form to DENY use of life prolonging procedures that would extend one’s life