Form Dhs 1277 - Service Questionnaire
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10Service Questionnaire
If you need assistance completing this form please call your vocational rehabilitation office before
your intake appointment.
This document can be provided upon request in an alternate format for individuals with disabilities or
in a language other than English for people with limited English skills. To request this form in another
format or language, contact Vocational Rehabilitation at 503-945-5880 or email vr.info@state.or.us or
711 for TTY.
Personal information
Last name:
First name:
Middle name:
Preferred name:
Previous last name:
Birthdate:
Email address:
Gender:
Social Security Number:
-
-
Phone number
cell
land
other:
Second phone number:
cell
land
other:
Home address:
Date residency began:
City:
State:
County:
ZIP code:
Mailing address (if different than above home address):
City:
State:
ZIP code:
Racial and ethnic background (check all that apply):
American Indian or Alaskan Native
Native Hawaiian or other Pacific Islander
Asian
White
Black or African American
Other (specify):
Hispanic or Latino
Primary language (check all that apply):
English
Spanish
Other:
Counselor notes:
Have you been a prior client of Vocational Rehabilitation?
Yes
No
If yes, when and where?
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DHS 1277 (10/2016)
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