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Home | Forms | DSB - Division of Services for the Blind DSB Home Page DSB Reimbursement of Travel Expenses (BD-403-ia) Criminal Record Check Consent Form (DHR-ESB-3004) Criminal Record Check Transmittal Form (DHR-ESB-3003) Form Subject Last Modified dhhs-1000-DSB-instructions DSB/ Authorization to Disclose Health Information Instructions 09/22/2009 dhhs-1000-ia DSB/ Authorization to Disclose Health Information 09/22/2009 dhhs-1000-sp-ia DSB/ Authorization to Disclose Health Information -Spanish 09/22/2009 dhhs-3531_dsb-0910-ia DSB/ Conference Authorization 10/01/2008 dhhs-WorkPlan-ia HR/ Department of Health and Human Services Work Plan 05/01/2009 dhs-I-9-DSB-VR-instructions VR/ Employment Eligibility Verification Instructions 05/28/2009 dhs-I-9-VR-ia 09/02/2009 dsb-0197-ILR-ia ILR/ Request for Residence Modification 05/27/2009 dsb-0197-ILR-instructions ILR/ Request for Residence Modification Instructions 05/27/2009 dsb-0311-ia DSB/ Employee Administration Request Form 08/12/2009 dsb-0502-ia DSB/ Travel Authorization and Training Registration 08/21/2009 dsb-0502-instructions DSB/ Travel Authorization and Training Registration Instruction 05/27/2009 dsb-0503-ia DSB/ Guide Service Billing Form 10/02/2009 dsb-0511-ia DSB/ Pharmacy Claim Form 10/01/2009 dsb-0511-instructions DSB/ Pharmacy Claim Instructions 12/11/2009 dsb-0612-ia DSB/ Staff Approved to Authorize Services, Approve Authorizations, and/or Approved Invoices 04/15/2009 dsb-0613-VR-ia VR/ Assignment of Reimbursement 07/20/2009 dsb-0613-VR-instructions VR/ Assignment of Reimbursement Instructions 05/27/2009 dsb-0950-ia DSB/ Verification of Items Received 07/14/2009 dsb-0950-instructions DSB/ Verification of Items Received Instructions 07/14/2009 dsb-1010-ia ILS/ Registrant Data Form 05/27/2009 dsb-2001-ia MED.EYE/ Application for Eye Care Certification 06/22/2009 dsb-2001-instructions MED.EYE/ Medical Eye Care Application Instructions 05/18/2009 dsb-2007-ia DSB/ Evaluation with Video Magnification (Closed Circuit Television) 05/27/2009 dsb-2007-instructions DSB/ Evaluation with Video Magnification (Closed Circuit Television) Instructions 05/27/2009 dsb-2031-ia MED.EYE/ Letter to Accompany Mailed Application 05/27/2009 dsb-2032-ia MED.EYE/ Notification of Need for Additional Information 05/27/2009 dsb-2032-instructions MED.EYE/ Notification of Need for Additional Information 05/27/2009 dsb-2033-ia MED.EYE/ Notification of Eligibility Status 05/27/2009 dsb-2033-instructions MED.EYE/ Notification of Eligibility Status 05/27/2009 dsb-2202-ia MED.EYE/ Report of Eye Examination 04/14/2009 dsb-2202-instructions MED.EYE/ Report of Eye Examination Instructions 05/27/2009 dsb-2205-A-ia DSB/ Referral for Low Vision Evaluation 05/27/2009 dsb-2205-A-instructions DSB/ Referral for Low Vision Evaluation Instructions 05/27/2009 dsb-2205-B-ia DSB/ Report on Low Vision Evaluation 12/04/2008 dsb-2207-ia MED.EYE/ Vision Screening List 05/27/2009 dsb-2207-instructions MED.EYE/ Vision Screening List Instructions 05/27/2009 dsb-2218-ia MED.EYE/ Permission Form for Vision Screening at Day Care 05/27/2009 dsb-2218-instructions MED.EYE/ Permission Form for Vision Screening at Day Care Instructions 05/27/2009 dsb-2220-ia MED.EYE/ Report to Parents of Child Screened at Day Care 05/27/2009 dsb-2220-instructions MED.EYE/ Report to Parents of Child Screened at Day Care Instructions 05/27/2009 dsb-4002-AT-ILR-ia ILR/ Referral for Assistive Technology Services 05/27/2009 dsb-4002-AT-ILR-instructions ILR/ Referral for Assistive Technology Services Instructions 05/27/2009 dsb-4002at-VR-ia VR/ Referral for Assistive Technology Services 06/18/2009 dsb-4002at-VR-instructions VR/ Referral for Assistive Technology Services Instructions 06/18/2009 dsb-4002-ILR-ia ILR/ Referral Form 05/27/2009 dsb-4002-ILR-instructions ILR/ Referral Form Instructions 05/27/2009 dsb-4002-VR-ia VR/ Referral Form 05/27/2009 dsb-4002-VR-instructions VR/ Referral Form Instructions 05/27/2009 dsb-4004b-ILR-ia ILR/ Independent Living Rehabilitation Agreement of Understanding with Applicant for Services 05/27/2009 dsb-4004b-ILR-instructions ILR/ Independent Living Rehabilitation Agreement of Understanding with Applicant for Services Instructions 06/04/2009 dsb-4004-ILR-ia ILR/ Independent Living Rehabilitation Application 05/27/2009 dsb-4004-ILR-instructions ILR/ Independent Living Rehabilitation Application Instructions 05/27/2009 dsb-4004-VR-ia VR/ Rehabilitation Application 07/20/2009 dsb-4004-VR-instructions VR/ Rehabilitation Application Instructions 05/27/2009 DSB-4005a-handbook-VR VR/ Vocational Rehabilitation Handbook 06/19/2009 dsb-4005a-ILR ILR/ Independent Living Plan 05/27/2009 dsb-4005a-VR-ia VR/ Agreement of Understanding with Applicant for Services 07/20/2009 dsb-4005a-VR-instructions VR/ Agreement of Understanding with Applicant for Services Instructions 06/18/2009 dsb-4005b-cont-VR-ia VR/ Individualized Plan for Employment (Continuation Page-Services) 07/20/2009 dsb-4005b-cont-VR-instructions VR/ Individualized Plan for Employment (Continuation Page-Services) Instructions 06/18/2009 dsb-4005b-ILR-ia ILR/ Independent Living Plan 05/27/2009 dsb-4005b-ILR-instructions ILR/ Independent Living Plan Instructions 06/04/2009 dsb-4005b-VR-ia VR/ Individualized Plan for Employment 07/20/2009 dsb-4005b-VR-instructions VR/ Individualized Plan for Employment Instructions 06/18/2009 dsb-4005c-ILR-ia ILR/ Independent Living Plan Continuation Page 05/27/2009 dsb-4005c-ILR-instructions ILR/ Independent Living Plan Continuation Page Instructions 06/04/2009 dsb-4005c-VR-ia VR/ Individualized Plan for Employment Closure Amendment 07/20/2009 dsb-4005c-VR-instructions VR/ Individualized Plan for Employment Closure Amendment Instructions 06/17/2009 dsb-4005d-ILR-ia ILR/ Independent Living Plan Amendment 05/27/2009 dsb-4005d-ILR-instructions ILR/ Independent Living Plan Amendment Instructions 06/04/2009 dsb-4005d-VR-ia VR/ Individualized Plan for Employment Amendment 07/20/2009 dsb-4005d-VR-instructions VR/ Individualized Plan for Employment Amendment Instructions 06/18/2009 dsb-4005-ILR-ia ILR/ Independent Living Closure Amendment 05/27/2009 dsb-4005-ILR-instructions ILR/ Independent Living Closure Amendment Instructions 06/04/2009 dsb-4009ojt-arra-VR-ia VR/ On-The-Job Training American Reinvestment and Recovery Act Agreement 09/23/2009 dsb-4009ojt-arra-VR-instructions VR/ On-The-Job Training American Reinvestment and Recovery Act Agreement Instructions 09/23/2009 dsb-4009ojt-m-VR-ia VR/ Modified On-The-Job Training Agreement 08/27/2009 dsb-4009ojt-m-VR-instructions VR/ Modified On-The-Job Training Agreement Instructions 08/27/2009 dsb-4009ojt-pr-VR-ia VR/ On-The-Job Training (OJT) Progress Report 08/27/2009 dsb-4009ojt-pr-VR-instructions VR/ On-The-Job Training (OJT) Progress Report Instructions 08/27/2009 dsb-4009ojt-VR-ia VR/ On-The-Job Training Agreement 08/27/2009 dsb-4009ojt-VR-instructions VR/ On-The-Job Training Agreement Instructions 08/27/2009 dsb-4009ojt-wrap-VR-ia VR/ On-The-Job Training Agreement Wage Reimbursement for Advanced Placement 07/20/2009 dsb-4009ojt-wrap-VR-instructions VR/ On-The-Job Training Agreement Wage Reimbursement for Advanced Placement Instructions 06/19/2009 dsb-4009wcc-a-VR-ia VR/ Request for Workers' Compensation Coverage 06/19/2009 dsb-4009wcc-a-VR-instructions VR/ Request for Workers' Compensation Coverage Instructions 06/19/2009 dsb-4009wcc-b-VR-ia VR/ Rehabilitation Individual Report of Injury 07/20/2009 dsb-4009wcc-b-VR-instructions VR/ Rehabilitation Individual Report of Injury Instructions 06/19/2009 dsb-4009wcc-c-VR-ia VR/ Rehabilitation Individual Incident Investigation Report 06/19/2009 dsb-4009wcc-c-VR-instructions VR/ Rehabilitation Individual Incident Investigation Report Instructions 06/19/2009 dsb-4009wcc-d-VR-ia VR/ Rehabilitation Individual Workers' Compensation Medical Authorization 07/20/2009 dsb-4009wcc-d-VR-instructions VR/ Rehabilitation Individual Workers' Compensation Medical Authorization Instructions 06/19/2009 dsb-4009wop-VR-ia VR/ Agreement for Work Experience without Pay 07/20/2009 dsb-4009wop-VR-instructions VR/ Agreement for Work Experience without Pay Instructions 06/18/2009 dsb-4011-ILR-ia ILR/ Case Progress Notes 05/27/2009 dsb-4011-ILR-instructions ILR/ Case Progress Notes Instructions 05/27/2009 dsb-4011-VR-ia VR/ Case Progress Notes 05/27/2009 dsb-4011-VR-instructions VR/ Case Progress Notes Instructions 05/27/2009 dsb-4016a-ILR-ia ILR/ Equipment and Computer Use Agreement 08/21/2009 dsb-4016a-ILR-instructions ILR/ Equipment and Computer Use Agreement Instructions 08/13/2009 dsb-4016-VR-ia VR/ Equipment and Computer Use Agreement 07/20/2009 dsb-4016-VR-instructions VR/ Equipment and Computer Use Agreement Instructions 05/27/2009 dsb-4017-ILR-ia ILR/ Authorization to Disclose Independent Living Rehabilitation Information 05/27/2009 dsb-4017-ILR-instructions ILR/ Authorization to Disclose Independent Living Rehabilitation Information Instructions 05/27/2009 dsb-4017-VR-ia VR/ Authorization to Disclose Vocational Rehabilitation Information 07/20/2009 dsb-4017-VR-instructions VR/ Authorization to Disclose Vocational Rehabilitation Information Instructions 05/27/2009 dsb-4020-ia DSB/ Pharmacy Agreement 12/10/2009 dsb-4033b-ILR-ia ILR/ Billing for Mini Center Instructors 05/27/2009 dsb-4033b-ILR-instructions ILR/ Billing for Mini Center Instructors Instructions 05/27/2009 dsb-4033-VR-ia VR/ Billing for Reader Service 07/20/2009 dsb-4033-VR-instructions VR/ Billing for Reader Service Instructions 05/27/2009 dsb-4040a-ILR-ia ILR/ Independent Living Rehabilitation Older Blind Economic Needs Survey 06/30/2009 dsb-4040a-ILR-instructions ILR/ Independent Living Rehabilitation Older Blind Economic Needs Survey Instructions 06/30/2009 dsb-4040-ILR-ia ILR/ Independent Living Rehabilitation Under 55 Economic Needs Survey 06/30/2009 dsb-4040-ILR-instructions ILR/ Independent Living Rehabilitation Under 55 Economic Needs Survey Instructions 06/30/2009 dsb-4040-VR-ia VR/ Economic Needs Survey 07/20/2009 dsb-4040-VR-instructions VR/ Economic Needs Survey Instructions 06/29/2009 dsb-4041-VR-ia VR/ Extension of Time to Determine Eligibility 07/20/2009 dsb-4041-VR-instructions VR/ Extension of Time to Determine Eligibility Instructions 05/27/2009 dsb-4042-ILR-ia ILR/ Authorization to Photograph/ Use Photograph/ Interview 05/27/2009 dsb-4042-ILR-instructions ILR/ Authorization to Photograph/ Use Photograph/ Interview Instructions 05/27/2009 dsb-4042-VR-ia VR/ Authorization to Photograph/ Use Photograph/ Interview 07/20/2009 dsb-4042-VR-instructions VR/ Authorization to Photograph/ Use Photograph/ Interview Instructions 05/27/2009 dsb-4043-ia ILS/ Mini-Center Mobility Report 05/27/2009 dsb-4044-VR-ia VR/ Deaf Blind Assessment 07/20/2009 dsb-4044-VR-instructions VR/ Deaf Blind Assessment Instructions 05/27/2009 dsb-4045-ILR-ia ILR/ Health Check List 05/27/2009 dsb-4045-ILR-instructions ILR/ Health Check List 05/27/2009 dsb-4045-VR-ia VR/ Health Check List 07/20/2009 dsb-4045-VR-instructions VR/ Health Check List Instructions 05/27/2009 dsb-4046-ia DSB/ DSB Outreach Report 05/27/2009 dsb-4047-VR-ia VR/ Low Vision Eye Doctor Evaluation Report 04/14/2009 dsb-4048-ia DSB/ Hearing Aid Agreement 05/27/2009 dsb-4048-instructions DSB/ Hearing Aid Agreement Instructions 05/27/2009 dsb-4049-ILR-ia ILR/ Independent Living Rehabilitation Counselor II Evaluation 05/27/2009 dsb-4049-VR-ia VR/ Vocational Rehabilitation Counselor II Evaluation 05/27/2009 dsb-4050-ILR-ia ILR/ Mini Center Narrative 05/27/2009 dsb-4050-ILR-instructions ILR/ Mini Center Narrative Instructions 05/27/2009 dsb-4051-ILR-ia ILR/ Independent Living Mini Center Survey 05/27/2009 dsb-4051-ILR-instructions ILR/ Independent Living Mini Center Survey Instructions 05/27/2009 dsb-4052-ILR-ia ILR/ Mini Center Instructor Evaluation Form 05/27/2009 dsb-4052-ILR-instructions ILR/ Mini Center Instructor Evaluation Form Instructions 05/27/2009 dsb-4054-ILR-ia ILR/ ILR Administrative P-Card Purchase Justification 05/27/2009 dsb-4054-ILR-instructions ILR/ ILR Administrative P-Card Purchase Justification Instructions 05/27/2009 dsb-4056-VR-ia VR/ Transition Technology Loan Agreement 07/20/2009 dsb-4056-VR-instructions VR/ Transition Technology Loan Agreement Instructions 05/27/2009 dsb-4057-ILR-ia ILR/ Mini Center Instructor Application 05/27/2009 dsb-4058-VR-ia VR/ Transportation Services 07/20/2009 dsb-4058-VR-instructions VR/ Transportation Services Instructions 05/27/2009 dsb-5056-BE-ia BE/ Training Evaluation 04/14/2009 dsb-5056-BE-instructions BE/ Training Evaluation Instructions 11/25/2008 dsb-5057-BE-ia BE/ On-The-Job Training Checklist for Levels I & II 04/14/2009 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 dsb-5064-BE-ia BE/ On-The-Job Training Agreement 04/14/2009 dsb-5064-BE-instructions BE/ On-The-Job Training Agreement Instructions 11/25/2008 dsb-7001-ia ILS/ Independent Living Services Program Application 05/27/2009 dsb-7080-ia ILS/ Cane Request Form 05/27/2009 dsb-7103-B-ia ILS/ Orientation and Mobility Services Plan 05/27/2009 dsb-7103-ia ILS/ Independent Living Services Program Assessment and Plan 05/27/2009 dsb-7103-instructions ILS/ Independent Living Services Program Assessment and Plan Instructions 05/18/2009 dsb-7108-ia ILS/ Agreement for In-Home Aide Services (Level- I Home Management) 05/27/2009 dsb-7219-ia ILS & MED.EYE/ Application for Conference 07/27/2009 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 dsb-7309-ia ILS/ Time Log for In-Home Service (Level I-Home Management) 05/27/2009 dsb-7311-ia ILS/ Training Record for In-Home Aide (Level I-Home Management) 05/27/2009 dsb-7399-ia ILS/ Forms Request 05/27/2009 dsb-7401-ILR-ia ILR/ Independent Living Eligibility Certification 05/27/2009 dsb-7401-ILR-instructions ILR/ Independent Living Eligibility Certification Instructions 05/27/2009 dsb-7402-ILR-ia ILR/ Independent Living Plan Waiver 05/27/2009 dsb-7402-ILR-instructions ILR/ Independent Living Plan Waiver Instructions 05/27/2009 dsb-7403-VR-ia VR/ Internship/Traineeship Agreement 07/20/2009 dsb-7403-VR-instructions VR/ Internship/Traineeship Agreement Instructions 05/27/2009 dsb-7404-ia ILS/ Notice: White Support Cane 02/09/2010 dsb-DrivingRecordStatus-ia ILS/ Driving Record Status Form 04/14/2009 dsb-DrivingRecordStatus-ILR-ia ILR/ Driving Record Status Form 04/14/2009 Form-2678-ia ILS/ Employer Appointment of Agent 11/09/2009 Form-i-9-ia 09/02/2009 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-VR-instructions VR/ Employer Appointment of Agent Instructions 01/13/2010 irs-2678-VR-ia VR/ Employer Appointment of Agent 11/09/2009 irs-w-9-DSB-instructions DSB/ Employer Appointment of Agent Instructions 05/28/2009 irs-w-9-ia DSB/ Request for Taxpayer Identification Number and Certification 05/28/2009 NC_Voter_Registration_Form DSB/ North Carolina Voter Registration Application 05/07/2009 Payment_Verification_Form-ia DSB/ Payment Verification Form 04/08/2008 PD-136-DSB-instructions DSB/Application for Academic Assistance Instructions 05/28/2009 PD-136-ia DSB/Application for Academic Assistance 12/07/2007 Request_Approval_Claim_Form MED.EYE/ Request for Prior Approval/ Claim Form for Eyeglasses 10/12/2007

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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