Fillable Form VA 28-1900 (2014-2017)

What is VA Form 28-1900?

VA Form 28-1900 or the Disabled Veterans Application for Vocational Rehabilitation form is used by U.S. veterans who are disabled to apply for and in need of assistance.

Who uses VA Form 28-1900?

U.S. veterans who have a combined and compensable service-connected disability rating of 10% are qualified for vocational rehabilitation services.

How to fill out VA Form 28-1900?

Before filling out the form, certain requirements must be met for you to qualify to apply for Vocational Rehabilitation Services. Read all necessary information and instructions to avoid committing errors. Do not input false or misleading information as it may result in penalties or imprisonment. After filling it out completely and legibly, double-check for any errors before submitting the form.

Purpose of Vocational Rehabilitation

The purpose of Vocational rehabilitation is to give assistance to disabled U.S. Veterans in need of a suitable job.

Read the Instructions Section of the form to see if you should fill out the form.

1. First, Middle, Last Name of Veteran

Enter your full legal name.

2. Social Security No.

Enter your Social Security number (SSN).

3. VA File No.

Enter the provided VA file number if different from Item 2.

4. Date of Birth

Enter your date of birth in the following format: Month, Day, Year

5A. Mailing Address

Enter your mailing address, including the number, street or rural route, city, state, and Zip Code.

5B. Email Address

Enter your email address if it is available.

6. Daytime Telephone No.

Enter your daytime telephone number. It may be a business or work number.

7. Evening Telephone No.

Enter your evening telephone number. It may be a fixed-line home number.

8. VA Office Where Records Are Located

Specify the VA office where your records are stored.

9. Number of years of education

Indicate the number of years of your education.

10. If you are moving within the next 30 days, give us your new address

Provide your would-be address if you are moving to a new home within the next 30 days.

11. List any previous Vocational Rehabilitation programs you have been in and give the dates (Include both VA and non-VA programs)

Indicate any Vocational Rehabilitation programs you have been in. There is a table provided on the form. In the first column, provide the program, on the second column, provide the date.

12. Service Information

Enter the following information for each period of active duty. Show all active duty. In this item, a table is provided wherein you will provide information for each period of your active duty.

• SERVICE NUMBER

Enter your service number

• BRANCH OF SERVICE

Enter your branch(es) of service

• DATE ENTERED ACTIVE DUTY

Enter the date when you entered active duty

• DATE LEFT ACTIVE DUTY

Enter the date when you left active duty

• TYPE OF SEPARATION OR DISCHARGE

Enter the type of separation or discharge from duty

13. If you are now working, enter the following information for your current job

• Name and Address of your employer

Enter the name and address of your current employer

• Duties of your job

Enter your duties of your current job

• Monthly salary or wages

Enter your current monthly salary or wages

14. If you are now hospitalized, what is the name and address of your hospital?

Provide the name and full address of your hospital if you are currently confined to one.

15A. What is your disability rating?

Indicate your disability rating

15B. What is the nature of your disability (disabilities)?

Provide the nature of your current disability/ies

16. Did you serve in:

Boxes will be provided for you to choose from. Mark the boxes that indicate the service you served in.

• World War II
• Post World War II Era
• Korean Conflict
• Post Korean Conflict
• Vietnam
• Post Vietnam
• Gulf War
• Operation Enduring Freedom
• Operation Iraqi Freedom

17. Disabled Transition Assistance Program (DTAP)?

The Disabled Transition Assistance Program helps those leaving military services as a result of disability to transition to civilian life. Mark Yes if you have received this program. Mark No if you have not received this program.

CERTIFICATION

The certification states that the information you have entered on this form is true and does not contain false or misleading information.

18A. Signature of Applicant

Enter your signature

18B. Date Signed

Enter the date when the application is being made

Page 2

The second page of the form provides the information and qualifications needed to apply for the service or assistance. You must read this page before filling out the form.

VOCATIONAL REHABILITATION FOR SERVICE-DISABLED VETERANS

TO APPLY OR RECEIVE INFORMATION AND ASSISTANCE

This form is to be submitted to the nearest VA office and you can find information on the VA website. You can also get information from veteran’s service organizations and the American Red Cross.

EVALUATION

If you have a service-connected disability rating of 10% or more, an evaluation will be provided for you when you apply for a rehabilitation program.

PLANNING AND COUNSELING

Counseling programs will be provided for you throughout your program. Your counselor will develop certain plans for you to achieve your goals.

REHABILITATION SERVICES

Your counselor will determine if you need training to achieve your vocational goals. You may acquire training from different facilities if your counselor deems it necessary.

SUPPORT

The VA will provide you with financial help such as tuition or any other fees that may arise during your program. You may receive allowances to help you meet your primary needs.

PRIVACY ACT

The privacy act law is presented in this application form. VA will not disclose the information provided on the form. All the information you have entered in this application form is kept only by you and the office of the VA.

RESPONDENT BURDEN

The information that you provide in this form is needed by the VA to help disabled veterans and provide them with assistance through Vocational Rehabilitation. The program is written in law under title 38, U.S.C. chapter 31.