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FormSubjectLast Modified
dhhs-1000-DSB-instructions DSB/ Authorization to Disclose Health Information Instructions 09/22/2009
Interactive Form dhhs-1000-ia DSB/ Authorization to Disclose Health Information 11/19/2010
Interactive Form dhhs-1000-sp-ia DSB/ Authorization to Disclose Health Information -Spanish 11/19/2010
Interactive Form dhhs-3531_dsb-0910-ia DSB/ Conference Authorization 10/01/2008
Interactive Form dhhs-WorkPlan-ia HR/ Department of Health and Human Services Work Plan 05/01/2009
Interactive Form dsb-0197-ILR-ia ILR/ Request for Residence Modification 11/19/2010
dsb-0197-ILR-instructions ILR/ Request for Residence Modification Instructions 05/27/2009
dsb-0311 DSB/ Employee Administration Request Form 07/25/2011
Interactive Form dsb-0502-ia DSB/ Travel Authorization and Training Registration 07/03/2013
dsb-0502-instructions DSB/ Travel Authorization and Training Registration Instructions 05/24/2012
Interactive Form dsb-0503-ia DSB/ Driver Service Billing Form 03/14/2012
Interactive Form dsb-0511-ia DSB/ Pharmacy Claim Form 03/18/2013
dsb-0511-instructions DSB/ Pharmacy Claim Instructions 03/18/2013
dsb-0525-DSB-instructions DSB/ DSB Accounts Receivable/ Refund Instructions 08/24/2011
Interactive Form dsb-0525-ia DSB/ DSB Accounts Receivable/ Refund 03/18/2011
Interactive Form dsb-0612-ia DSB/ Staff Approved to Authorize Services, Approve Authorizations, and/or Approved Invoices 04/15/2009
Interactive Form dsb-0613-VR-ia VR/ Assignment of Reimbursement 11/19/2010
dsb-0613-VR-instructions VR/ Assignment of Reimbursement Instructions 05/27/2009
Interactive Form dsb-0950-ia DSB/ Verification of Items Received 11/19/2010
dsb-0950-instructions DSB/ Verification of Items Received Instructions 07/14/2009
Interactive Form dsb-1010-ia 02/04/2014
Interactive Form dsb-2001-ia MED.EYE/ Application for Eye Care Certification 10/21/2013
dsb-2001-instructions MED.EYE/ Application for Eye Care Certification Instructions 09/20/2010
Interactive Form dsb-2007-ia DSB/ Evaluation with Video Magnification (Closed Circuit Television) 11/19/2010
dsb-2007-instructions DSB/ Evaluation with Video Magnification (Closed Circuit Television) Instructions 05/27/2009
Interactive Form dsb-2031-ia MED.EYE/ Letter to Accompany Mailed Application 11/19/2010
Interactive Form dsb-2032-ia MED.EYE/ Notification of Need for Additional Information 11/19/2010
dsb-2032-instructions MED.EYE/ Notification of Need for Additional Information 05/27/2009
Interactive Form dsb-2033-ia MED.EYE/ Notification of Eligibility Status 11/22/2011
dsb-2033-instructions MED.EYE/ Notification of Eligibility Status 05/27/2009
Interactive Form dsb-2202-ia DSB/ Report of Eye Examination 02/23/2012
dsb-2202-instructions DSB/ Report of Eye Examination Instructions 02/23/2012
Interactive Form dsb-2205-A-ia DSB/ Referral for Low Vision Evaluation 11/19/2010
dsb-2205-A-instructions DSB/ Referral for Low Vision Evaluation Instructions 05/27/2009
Interactive Form dsb-2205-B-ia DSB/ Report on Low Vision Evaluation 11/19/2010
Interactive Form dsb-2207-ia MED.EYE/ Vision Screening List 11/19/2010
dsb-2207-instructions MED.EYE/ Vision Screening List Instructions 05/27/2009
Interactive Form dsb-2218-ia MED.EYE/ Permission Form for Vision Screening at Day Care 11/19/2010
dsb-2218-instructions MED.EYE/ Permission Form for Vision Screening at Day Care Instructions 05/27/2009
Interactive Form dsb-2220-ia MED.EYE/ Report to Parents of Child Screened at Day Care 11/19/2010
dsb-2220-instructions MED.EYE/ Report to Parents of Child Screened at Day Care Instructions 05/27/2009
Interactive Form dsb-4002-AT-ILR-ia ILR/ Referral for Assistive Technology Services 11/19/2010
dsb-4002-AT-ILR-instructions ILR/ Referral for Assistive Technology Services Instructions 05/27/2009
Interactive Form dsb-4002at-VR-ia VR/ Referral for Assistive Technology Services 11/19/2010
dsb-4002at-VR-instructions VR/ Referral for Assistive Technology Services Instructions 08/26/2010
Interactive Form dsb-4002-ILR-ia ILR/ Referral Form 11/19/2010
dsb-4002-ILR-instructions ILR/ Referral Form Instructions 05/27/2009
Interactive Form dsb-4002-VR-ia VR/ Referral Form 11/19/2010
dsb-4002-VR-instructions VR/ Referral Form Instructions 05/27/2009
Interactive Form dsb-4004b-ILR-ia ILR/ Independent Living Rehabilitation Agreement of Understanding with Applicant for Services 06/03/2011
dsb-4004b-ILR-instructions ILR/ Independent Living Rehabilitation Agreement of Understanding with Applicant for Services Instructions 06/04/2009
Interactive Form dsb-4004-ILR-ia ILR/ Independent Living Rehabilitation Application 11/19/2010
dsb-4004-ILR-instructions ILR/ Independent Living Rehabilitation Application Instructions 07/16/2010
Interactive Form dsb-4004-VR-ia VR/ Rehabilitation Application 11/19/2010
dsb-4004-VR-instructions VR/ Rehabilitation Application Instructions 05/27/2009
DSB-4005a-handbook-VR VR/ Vocational Rehabilitation Handbook 03/31/2011
dsb-4005a-ILR ILR/ Independent Living Plan 05/27/2009
Interactive Form dsb-4005a-VR-ia VR/ Agreement of Understanding with Applicant for Services 03/31/2011
dsb-4005a-VR-instructions VR/ Agreement of Understanding with Applicant for Services Instructions 06/18/2009
Interactive Form dsb-4005b-cont-VR-ia VR/ Individualized Plan for Employment (Continuation Page-Services) 11/19/2010
dsb-4005b-cont-VR-instructions VR/ Individualized Plan for Employment (Continuation Page-Services) Instructions 06/18/2009
Interactive Form dsb-4005b-ILR-ia ILR/ Independent Living Plan 11/19/2010
dsb-4005b-ILR-instructions ILR/ Independent Living Plan Instructions 06/04/2009
Interactive Form dsb-4005b-VR-ia VR/ Individualized Plan for Employment 11/19/2010
dsb-4005b-VR-instructions VR/ Individualized Plan for Employment Instructions 03/25/2010
Interactive Form dsb-4005c-ILR-ia ILR/ Independent Living Plan Continuation Page 11/19/2010
dsb-4005c-ILR-instructions ILR/ Independent Living Plan Continuation Page Instructions 06/04/2009
Interactive Form dsb-4005c-VR-ia VR/ Individualized Plan for Employment Closure Amendment 11/19/2010
dsb-4005c-VR-instructions VR/ Individualized Plan for Employment Closure Amendment Instructions 09/22/2010
Interactive Form dsb-4005d-ILR-ia ILR/ Independent Living Plan Amendment 11/19/2010
dsb-4005d-ILR-instructions ILR/ Independent Living Plan Amendment Instructions 06/04/2009
Interactive Form dsb-4005d-VR-ia VR/ Individualized Plan for Employment Amendment 11/19/2010
dsb-4005d-VR-instructions VR/ Individualized Plan for Employment Amendment Instructions 03/09/2010
dsb-4005e DSB/ Code of Conduct 06/03/2011
Interactive Form dsb-4005-ILR-ia ILR/ Independent Living Closure Amendment 11/19/2010
dsb-4005-ILR-instructions ILR/ Independent Living Closure Amendment Instructions 06/04/2009
Interactive Form dsb-4009ojt-m-VR-ia VR/ Modified On-The-Job Training Agreement 11/19/2010
dsb-4009ojt-m-VR-instructions VR/ Modified On-The-Job Training Agreement Instructions 08/27/2009
Interactive Form dsb-4009ojt-pr-VR-ia VR/ On-The-Job Training (OJT) Progress Report 11/19/2010
dsb-4009ojt-pr-VR-instructions VR/ On-The-Job Training (OJT) Progress Report Instructions 07/15/2010
Interactive Form dsb-4009ojt-VR-ia VR/ On-The-Job Training Agreement 11/19/2010
dsb-4009ojt-VR-instructions VR/ On-The-Job Training Agreement Instructions 08/27/2009
Interactive Form dsb-4009ojt-wrap-VR-ia VR/ On-The-Job Training Agreement Wage Reimbursement for Advanced Placement 11/19/2010
dsb-4009ojt-wrap-VR-instructions VR/ On-The-Job Training Agreement Wage Reimbursement for Advanced Placement Instructions 06/19/2009
Interactive Form dsb-4009wcc-a-VR-ia VR/ Request for Workers' Compensation Coverage 11/19/2010
dsb-4009wcc-a-VR-instructions VR/ Request for Workers' Compensation Coverage Instructions 06/19/2009
Interactive Form dsb-4009wcc-b-VR-ia VR/ Rehabilitation Individual Report of Injury 11/19/2010
dsb-4009wcc-b-VR-instructions VR/ Rehabilitation Individual Report of Injury Instructions 06/19/2009
Interactive Form dsb-4009wcc-c-VR-ia VR/ Rehabilitation Individual Incident Investigation Report 11/19/2010
dsb-4009wcc-c-VR-instructions VR/ Rehabilitation Individual Incident Investigation Report Instructions 06/19/2009
Interactive Form dsb-4009wcc-d-VR-ia VR/ Rehabilitation Individual Workers' Compensation Medical Authorization 11/19/2010
dsb-4009wcc-d-VR-instructions VR/ Rehabilitation Individual Workers' Compensation Medical Authorization Instructions 06/19/2009
Interactive Form dsb-4009wop-VR-ia VR/ Agreement for Work Experience without Pay 11/19/2010
dsb-4009wop-VR-instructions VR/ Agreement for Work Experience without Pay Instructions 07/15/2010
Interactive Form dsb-4011-ILR-ia ILR/ Case Progress Notes 11/19/2010
dsb-4011-ILR-instructions ILR/ Case Progress Notes Instructions 05/27/2009
Interactive Form dsb-4011-VR-ia VR/ Case Progress Notes 11/19/2010
dsb-4011-VR-instructions VR/ Case Progress Notes Instructions 05/27/2009
Interactive Form dsb-4016a-ILR-ia ILR/ Equipment and Computer Use Agreement 11/19/2010
dsb-4016a-ILR-instructions ILR/ Equipment and Computer Use Agreement Instructions 08/13/2009
Interactive Form dsb-4016-ia DSB/ Equipment and Computer Use Agreement 11/19/2010
dsb-4016-instructions DSB/ Equipment and Computer Use Agreement Instructions 09/21/2010
Interactive Form dsb-4017-ILR-ia ILR/ Authorization to Disclose Independent Living Rehabilitation Information 11/19/2010
dsb-4017-ILR-instructions ILR/ Authorization to Disclose Independent Living Rehabilitation Information Instructions 07/16/2010
Interactive Form dsb-4017-VR-ia VR/ Authorization to Disclose Vocational Rehabilitation Information 11/19/2010
dsb-4017-VR-instructions VR/ Authorization to Disclose Vocational Rehabilitation Information Instructions 07/15/2010
Interactive Form dsb-4020-ia DSB/ Pharmacy Agreement 12/10/2009
Interactive Form dsb-4033b-ILR-ia ILR/ Billing for Mini Center Instructors 05/24/2013
dsb-4033b-ILR-instructions ILR/ Billing for Mini Center Instructors Instructions 05/24/2013
Interactive Form dsb-4033-VR-ia VR/ Billing for Reader Service 11/19/2010
dsb-4033-VR-instructions VR/ Billing for Reader Service Instructions 05/27/2009
Interactive Form dsb-4040-ia VR/ ILR Financial Needs Survey 09/09/2013
dsb-4040-instructions VR/ ILR Financial Needs Survey Instructions 07/12/2013
Interactive Form dsb-4041-VR-ia VR/ Extension of Time to Determine Eligibility 11/19/2010
dsb-4041-VR-instructions VR/ Extension of Time to Determine Eligibility Instructions 05/27/2009
Interactive Form dsb-4042-ILR-ia ILR/ Authorization to Photograph/ Use Photograph/ Interview 11/19/2010
dsb-4042-ILR-instructions ILR/ Authorization to Photograph/ Use Photograph/ Interview Instructions 05/27/2009
Interactive Form dsb-4042-VR-ia VR/ Authorization to Photograph/ Use Photograph/ Interview 11/19/2010
dsb-4042-VR-instructions VR/ Authorization to Photograph/ Use Photograph/ Interview Instructions 05/27/2009
Interactive Form dsb-4043-ia ILS/ Mini-Center Mobility Report 11/19/2010
Interactive Form dsb-4044-VR-ia VR/ Deaf Blind Assessment 11/19/2010
dsb-4044-VR-instructions VR/ Deaf Blind Assessment Instructions 05/27/2009
Interactive Form dsb-4045-ILR-ia ILR/ Health Check List 11/19/2010
dsb-4045-ILR-instructions ILR/ Health Check List 05/27/2009
Interactive Form dsb-4045-VR-ia VR/ Health Check List 11/19/2010
dsb-4045-VR-instructions VR/ Health Check List Instructions 05/27/2009
Interactive Form dsb-4046-ia DSB/ DSB Outreach Report 01/31/2012
Interactive Form dsb-4047a-VR-ia VR/ Low Vision Eye Doctor Evaluation Report Addendum 04/01/2011
Interactive Form dsb-4047-VR-ia VR/ Low Vision Eye Doctor Evaluation Report 07/15/2010
Interactive Form dsb-4048-ia DSB/ Hearing Aid Agreement 11/19/2010
dsb-4048-instructions DSB/ Hearing Aid Agreement Instructions 05/27/2009
Interactive Form dsb-4049-ILR-ia ILR/ Independent Living Rehabilitation Counselor II Evaluation 11/19/2010
Interactive Form dsb-4049-VR-ia VR/ Vocational Rehabilitation Counselor II Evaluation 11/19/2010
Interactive Form dsb-4050-ILR-ia ILR/ Mini Center Narrative 11/19/2010
dsb-4050-ILR-instructions ILR/ Mini Center Narrative Instructions 05/27/2009
Interactive Form dsb-4051-ILR-ia ILR/ Independent Living Mini Center Survey 11/19/2010
dsb-4051-ILR-instructions ILR/ Independent Living Mini Center Survey Instructions 05/27/2009
Interactive Form dsb-4052-ILR-ia ILR/ Mini Center Instructor Evaluation Form 11/19/2010
dsb-4052-ILR-instructions ILR/ Mini Center Instructor Evaluation Form Instructions 07/19/2010
Interactive Form dsb-4054-ILR-ia ILR/ ILR Administrative P-Card Purchase Justification 11/19/2010
dsb-4054-ILR-instructions ILR/ ILR Administrative P-Card Purchase Justification Instructions 05/27/2009
Interactive Form dsb-4056-VR-ia VR/ Transition Technology Loan Agreement 11/19/2010
dsb-4056-VR-instructions VR/ Transition Technology Loan Agreement Instructions 05/27/2009
Interactive Form dsb-4057-ILR-ia ILR/ Mini Center Instructor Application 11/19/2010
Interactive Form dsb-4058-VR-ia VR/ Transportation Services 11/19/2010
dsb-4058-VR-instructions VR/ Transportation Services Instructions 05/27/2009
Interactive Form dsb-5056-BE-ia BE/ Training Evaluation 11/19/2010
dsb-5056-BE-instructions BE/ Training Evaluation Instructions 11/25/2008
Interactive Form dsb-5057-BE-ia BE/ On-The-Job Training Checklist for Levels I & II 11/19/2010
dsb-5057-BE-instructions BE/ On-The-Job Training Checklist for Levels I & II Instructions 11/25/2008
dsb-5058-BE BE/ On-The-Job Training Guide For Levels I & II 11/25/2008
Interactive Form dsb-5064-BE-ia BE/ On-The-Job Training Agreement 10/09/2013
dsb-5064-BE-instructions BE/ On-The-Job Training Agreement Instructions 11/25/2008
Interactive Form dsb-5065-BE-ia BE/ On-The-Job Trainer Invoice 10/10/2013
dsb-5065-BE-instructions BE/ On-The-Job Trainer Invoice Instructions 10/10/2013
Interactive Form dsb-7001-ia ILS/ Independent Living Services Program Application 04/06/2011
Interactive Form dsb-7080-ia ILS/ Cane Request Form 11/19/2010
Interactive Form dsb-7103-B-ia ILS/ Orientation and Mobility Service Plan 11/19/2010
Interactive Form dsb-7103-ia ILS/ Independent Living Services Program Assessment and Plan 11/19/2010
dsb-7103-instructions ILS/ Independent Living Services Program Assessment and Plan Instructions 05/18/2009
Interactive Form dsb-7108-ia ILS/ Agreement for In-Home Aide Services: Level I- Home Management 11/19/2010
Interactive Form dsb-7219-ia ILS & MED.EYE/ Application for Conference 11/19/2010
dsb-7219-instructions ILS & MED.EYE/ Application for Conference Instructions 07/27/2009
dsb-7222 SAB/ dsb-7222 03/26/2009
dsb-7223 SAB/ dsb-7223 03/26/2009
dsb-7224 SAB/ dsb-7224 03/26/2009
dsb-7225 SAB/ dsb-7225 03/26/2009
Interactive Form dsb-7309-ia ILS/ Time Log for In-Home Service (Level I-Home Management) 11/19/2010
Interactive Form dsb-7311-ia ILS/ Training Record for In-Home Aide (Level I-Home Management) 11/19/2010
Interactive Form dsb-7399-ia ILS/ Forms Request 11/19/2010
Interactive Form dsb-7401-ILR-ia ILR/ Independent Living Eligibility Certification 11/19/2010
dsb-7401-ILR-instructions ILR/ Independent Living Eligibility Certification Instructions 05/27/2009
Interactive Form dsb-7402-ILR-ia ILR/ Independent Living Plan Waiver 11/19/2010
dsb-7402-ILR-instructions ILR/ Independent Living Plan Waiver Instructions 05/27/2009
Interactive Form dsb-7403-VR-ia VR/ Internship/ Traineeship Agreement 12/02/2011
dsb-7403-VR-instructions VR/ Internship/ Traineeship Agreement Instructions 12/02/2011
Interactive Form dsb-7404-ia ILS/ Notice: White Support Cane 01/28/2014
Interactive Form dsb-7405-ia DSB/ Confidentiality Statement for Drivers 02/28/2012
Interactive Form dsb-7406-ia DSB/ Code of Conduct Violation Incident Report 02/28/2012
Interactive Form dsb-7407-ia DSB/ Code of Conduct Violation Investigation Report 04/12/2013
Interactive Form dsb-DrivingRecordStatus-ia ILS/ Driving Record Status Form 11/19/2010
Interactive Form dsb-DrivingRecordStatus-ILR-ia ILR/ Driving Record Status Form 11/19/2010
HCFA-1500 MED.EYE/ Health Insurance Claim Form 07/14/2009
HCFA-1500-instructions MED.EYE/ Health Insurance Claim Form Instructions 07/08/2009
IRS-2678-DSB-Instructions DSB/ Employer Appointment of Agent Instructions 09/27/2010
Interactive Form IRS-2678-ia Employer/ Payer Appointment of Agent 11/19/2010
IRS-I-9-DSB-Instructions Employment Eligibility Verification Instructions 09/27/2010
Interactive Form IRS-I-9-ia 11/19/2010
IRS-W-9-DSB-Instructions Request for Taxpayer Identification Number and Certification Instructions 06/22/2010
Interactive Form irs-w-9-ia DSB/ Request for Taxpayer Identification Number and Certification 11/19/2010
NC_Voter_Registration_Form DSB/ Voter Registration Form 02/16/2011
NC_VR_Agency_Transmittal_Form DSB/ NC Voter Registration Agency Transmittal Form 03/30/2010
NC_VR_Preference_Form DSB/ NC Voter Registration Preference Form 03/30/2010
NC_VR_Preference_Form-sp DSB/ NC Voter Registration Preference Form- Spanish 03/30/2010
NC_VR_Supplies_Order_Form DSB/ NC Voter Registration Supplies Order Form 11/19/2010
PA-2 N.C. DHHS: PA-2 N.C. DHHS Public Affairs Review 10/24/2011
Interactive Form Payment_Verification_Form-ia DSB/ Payment Verification Form 04/08/2008
PD-136-DSB-instructions DSB/Application for Academic Assistance Instructions 05/28/2009
Interactive Form PD-136-ia DSB/Application for Academic Assistance 11/19/2010
Request_Prior_Approval_Claim_Form_for_Eyeglasses DSB/ Request Prior Approval Claim Form for Eyeglasses 06/15/2010
Teacher Certification NC DHHS Teacher Evaluation Process Pre-Observation NC DHHS Teacher Evaluation Process Pre-Observation 08/09/2010
Teacher Certification NC DHHS Teacher Evaluation Process Timeline NC DHHS Teacher Evaluation Process Timeline 08/26/2010
Teacher Certification NC DHHS Teacher Individual Growth Plan NC DHHS Teacher Individual Growth Plan 09/16/2010
Teacher Certification NC DHHS Teacher Summary Rating Form NC DHHS Teacher Summary Rating Form 08/09/2010
Teacher Certification NC Teacher Evaluation Process for DHHS NC Teacher Evaluation Process for DHHS 08/26/2010
Teacher Certification Post-Observation Conference Documentation Post-Observation Conference Documentation 08/09/2010
Teacher Certification Rubric for Evaluating DHHS Teachers Rubric for Evaluating DHHS Teachers 08/09/2010
Teacher Certification Rubric for Evaluating NC Teachers Rubric for Evaluating NC Teachers 08/09/2010
Teacher Certification Teacher Observation Form Teacher Observation Form 08/09/2010
 


For questions or clarification on any of the policy contained in these manuals and forms, please contact your local county office.

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