Form Rsa-1298a - Referral Form Page 3
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3RSA-1298AFORFF (10-17) - PAGE 3
What is your disability(ies)? Please check all that apply.
BEHAVIORAL HEALTH
PHYSICAL
BLIND OR VISUALLY IMPAIRED
DEAF OR HARD OF HEARING
DEVELOPMENTAL DELAY
COGNITIVE DELAY
OTHER: (PLEASE DESCRIBE)
What are you hoping Rehabilitation Services can help you with?
Are you a family member or close associate of an RSA program employee?
YES
NO
Optional: Please disclose the name of the family member or close associate.
DATE SUBMITTED:
Equal Opportunity Employer/Program • Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the Amer-
icans with Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975,
and Title II of the Genetic Information Nondiscrimination Act (GINA) of 2008; the Department prohibits discrimination in
admissions, programs, services, activities, or employment based on race, color, religion, sex, national origin, age, disability,
genetics and retaliation. To request this document in alternative format or for further information about this policy, call 1-800-
563-1221 Services: 7-1-1. • Free language assistance for DES services is available upon request. Ayuda gratuita con traduc-
ciones relacionadas con los servicios del DES esta disponible a solicitud del cliente.
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