Kitty Zachery (502) 955-7271 | KittyZachery@CoalitionFWD.com

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Online Placement Report Form

by Coalition | Apr 12, 2021 | Form | 0 comments

Placement Form

Client Name*
VR Case Number
VR Case Status
- Open
- Closed
Gender*
- Female
- Male
Race*
- Black
- White
- Asian
- Multiracial
Veteran*
- Yes
- No
Client's Home ZIP Code*
Primary Disability*
Secondary Disability
Education Level*
Employer*
Other Employer
Job Title*
Start Date*
Date Format: MM slash DD slash YYYY
Hours Per Week*
Job Duties*
Wage*
Job Type*
- Training
- Temporary
- Permanent Part Time
- Permanent Full Time
Benefits*
- None
- After 30 Days
- After 60 Days
- After 90 Days
- Other
Other Benefit Eligibility
VR Counselor*
Employment Specialist*
Agency Name*
Email Address of Person Submitting Form*

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