Form VA Form 28-1902w VA Form 28-1902w Veteran Readiness and Employment (VR&E) Questionnaire (C

OMB Control No. 2900-0092
Respondent Burden: 45 Minutes
Expiration Date: XX/XX/XXXX

VA DATE STAMP
(DO NOT WRITE IN THIS SPACE)

VETERAN READINESS AND EMPLOYMENT (VR&E) QUESTIONNAIRE
INSTRUCTIONS: Before completing this form, read the Privacy Act and Respondent Burden on
page 6. Use this form to assist in the determination of entitlement to Chapter 31 benefits. For more
information, contact us at https://iris.custhelp.va.gov, or call us toll-free at 1-800-827-1000. If you
use a Telecommunications Device for the Deaf (TDD), the Federal relay number is 711. VA forms
are available at www.va.gov/vaforms. After completing the form, if returning by mail, mail to
Veteran Readiness and Employment (VR&E) Intake Center, Department of Veterans Affairs, P.O.
Box 5210, Janesville, WI, 53547-5210.
SECTION I: CLAIMANT'S INFORMATION
NOTE: You may either complete the form online or by hand. If completed by hand, print the information requested in ink, neatly, and legibly to expedite
processing of the form.
1. NAME (First, Middle Initial, Last)

2. VA FILE NUMBER

3. DATE OF BIRTH (MM/DD/YYYY)

4. CURRENT MAILING ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)
No. &
Street
Apt./Unit Number

City
Country

State/Province

ZIP Code/Postal Code

5. TELEPHONE NUMBER (Include Area Code)

6. EMAIL ADDRESS (Optional)

I agree to receive electronic correspondence
from VA In regards to my claim.

Enter International Phone Number (If applicable)

8. MARITAL STATUS

7. GENDER
MALE

FEMALE

NON BINARY/THIRD GENDER

MARRIED

DIVORCED

SEPARATED

WIDOWED

NEVER
MARRIED

SECTION II: EMERGENCY CONTACT INFORMATION
9. CONTACT'S NAME (First, Middle Initial, Last)

10. CONTACT'S TELEPHONE NUMBER (Include Area Code)

11. CONTACT'S RELATIONSHIP TO CLAIMANT (Describe)

Enter International Phone Number (If applicable)

SECTION III: CLAIMANT'S BACKGROUND INFORMATION
12. HOW DO YOU EXPECT THIS PROGRAM TO HELP YOU? (Explain)

13. WHAT ARE THE JOBS OR CAREER FIELDS YOU ARE MOST INTERESTED IN PURSUING? (Explain)

14. HAVE YOU EVER PARTICIPATED IN OR ARE CURRENTLY PARTICIPATING IN A VA EDUCATION BENEFIT PROGRAM?
YES
VA FORM
XXX XXXX

NO

28-1902w

SUPERSEDES VA FORM 28-1902w, SEP 2015,
WHICH WILL NOT BE USED

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SECTION III: CLAIMANT'S BACKGROUND INFORMATION (Continued)
15. HAVE YOU EVER PARTICIPATED IN A PROGRAM OF
VOCATIONAL REHABILITATION BEFORE?
YES
NO
(If "Yes," complete Item 16)

16. CHECK ALL THAT APPLY IN WHICH YOU HAVE PARTICIPATED
WORKER'S COMP
VA VOCATIONAL REHABILITATION
PRIVATE
STATE VOCATIONAL REHABILITATION

OTHER (Explain)

17. LIST ANY TYPE OF SERVICES YOU WERE PROVIDED (i.e., training, medical, vocational testing, functional capacities, job search activities):

SECTION IV: CIVILIAN EMPLOYMENT
(Please fill out each area as completely as possible. If you have a resume attach it to the completed form)
18. CIVILIAN EMPLOYMENT HISTORY: Please start with your most current position.
JOB TITLE

DATES (MM/DD/YYYY)

AVERAGE GROSS MONTHLY SALARY

FROM

.00

$

TO
COMPANY NAME

STATUS
FULL TIME
PART TIME

DESCRIBE JOB DUTIES IN DETAIL

REASON FOR LEAVING

JOB TITLE

DATES (MM/DD/YYYY)

AVERAGE GROSS MONTHLY SALARY

FROM

.00

$

TO
COMPANY NAME

STATUS
FULL TIME
PART TIME

DESCRIBE JOB DUTIES IN DETAIL

REASON FOR LEAVING

JOB TITLE

DATES (MM/DD/YYYY)

AVERAGE GROSS MONTHLY SALARY

FROM
TO
COMPANY NAME

.00

$
STATUS
FULL TIME
PART TIME

DESCRIBE JOB DUTIES IN DETAIL

REASON FOR LEAVING

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SECTION IV: CIVILIAN EMPLOYMENT (Continued)
(Please fill out each area as completely as possible. If you have a resume attach it to the completed form)
DATES (MM/DD/YYYY)

JOB TITLE

AVERAGE GROSS MONTHLY SALARY

FROM

.00

$

TO
COMPANY NAME

STATUS
FULL TIME
PART TIME

DESCRIBE JOB DUTIES IN DETAIL

REASON FOR LEAVING

SECTION V: MILITARY WORK HISTORY
(Please fill out the following area as completely as possible)
19. MILITARY WORK HISTORY: Please start with your most current Military Occupation Specialty (MOS).
BRANCH OF SERVICE:

ARMY

NAVY

MARINES

JOB TITLE

COAST GUARD

AIR FORCE

DATES (MM/DD/YYYY)

SPACE FORCE
AVERAGE GROSS MONTHLY SALARY

FROM

$

TO
LIST ANY HONORS AND COMMENDATIONS

.00

RANK

DESCRIBE JOB DUTIES IN DETAIL

BRANCH OF SERVICE:

ARMY

NAVY

MARINES

JOB TITLE

COAST GUARD

AIR FORCE

DATES (MM/DD/YYYY)

SPACE FORCE
AVERAGE GROSS MONTHLY SALARY

FROM

$

TO

.00

RANK

LIST ANY HONORS AND COMMENDATIONS

DESCRIBE JOB DUTIES IN DETAIL

ARMY

BRANCH OF SERVICE:

NAVY

MARINES

COAST GUARD

AIR FORCE

DATES (MM/DD/YYYY)

JOB TITLE

SPACE FORCE
AVERAGE GROSS MONTHLY SALARY

FROM
TO
LIST ANY HONORS AND COMMENDATIONS

$

.00

RANK

DESCRIBE JOB DUTIES IN DETAIL

VA FORM 28-1902w, XXX XXXX

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SECTION VI: ADDITIONAL EMPLOYMENT INFORMATION
(Please fill out the following area as completely as possible)
20. WHAT WORK SKILLS DID YOU USE IN YOUR CURRENT OR PREVIOUS POSITIONS THAT YOU THINK YOU MAY BE ABLE TO USE IN A
NEW JOB?

21. PLEASE EXPLAIN WHAT YOU DID DURING PERIODS OF UNEMPLOYMENT OF 3 MONTHS OR LONGER:

VII: EDUCATION AND TRAINING
Please fill out the area below regarding your education/training background as completely as possible.
Please include vocational, college, on-the-job, and other training. NOTE: Please include civilian and military schools/training.
22. INDICATE HIGHEST LEVEL COMPLETED:
SOME HS

HS

GED

ASSOCIATE

BACHELOR

MASTER

POST GRADUATE

NOTE: Attach college transcript if applicable and available.
23A. LIST CERTIFICATES/LICENSES (Apprentices or journeyman card, truck driver/CDL, etc.)

23B. DATE EXPIRES
(MM/DD/YYYY)

VIII: LIST AND DESCRIBE ALL OF YOUR SERVICE-CONNECTED AND NON SERVICE-CONNECTED DISABILITY(IES)
(Please list the disability(ies) in order of severity)
24A. SERVICE-CONNECTED DISABILITY(IES)

24B. WHAT DIFFICULTIES ARE YOU EXPERIENCING
DUE TO YOUR DISABILITY(IES)?

25A. NON SERVICE-CONNECTED DISABILITY(IES)

25B. WHAT DIFFICULTIES ARE YOU EXPERIENCING
DUE TO YOUR DISABILITY(IES)?

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VIII: DISABILITY(IES) (Continued)
25C. HAS/HAVE YOUR SERVICE CONNECTED DISABILITY(IES) AFFECTED YOU IN THE FOLLOWING AREAS OF WORK? (Check all that apply)
JOB PERFORMANCE

JOB OPPORTUNITIES

CO-WORKER RELATIONS

JOB SATISFACTION

MISSED WORK TIME

MANAGER RELATIONS

26. ARE ANY OF YOUR DISABILITIES
IMPROVING?
YES

NO

27. ARE ANY OF YOUR DISABILITIES
STABLE?
YES

OTHER (Please explain)

28. ARE ANY OF YOUR DISABILITIES
WORSENING?

NO

YES

NO

29. DO YOU RECEIVE OR HAVE A PENDING CLAIM FOR ANY OF THE FOLLOWING? (Check all that apply)
RETIREMENT (Military/civilian)

WORKERS COMPENSATION BENEFITS

WELFARE ASSISTANCE

DISABILITY PENSION (Military/civilian)

SOCIAL SECURITY DISABILITY INCOME (SSDI/SSI)

MEDICARE/MEDICAID

UNEMPLOYMENT

TOTAL DISABILITY BASED ON INDIVIDUAL
UNEMPLOYABILITY (TDIU)

OTHER

IX: MEDICAL TREATMENT
(Please describe ALL medical treatment you are receiving outside of VA)
30A. CONDITION

30B. NAME OF MEDICAL FACILITY

30C. HOW OFTEN ARE YOU SEEN
FOR TREATMENT

31A. DO YOU HAVE MEDICAL NEEDS THAT ARE NOT BEING MET? (If "Yes," complete Item 31B)
YES

NO

31B. WHAT WOULD HELP ADDRESS YOUR UNMET MEDICAL NEEDS?

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X: MISCELLANEOUS
(The following information will be used for employment planning purposes)
33. DO YOU HAVE A VALID DRIVER'S LICENSE?

32. HOW FAR ARE YOU WILLING TO COMMUTE FOR WORK AND OR SCHOOL?
Number of miles

YES

Number of hours

OR

NO

34. ARE YOU WILLING TO RELOCATE FOR A JOB?
YES

NO

35. IF YOU HAVE HAD A HISTORY OF OR ARE CURRENTLY DEALING WITH LEGAL ISSUES, PLEASE SELECT AND DESCRIBE BELOW:
BANKRUPTCY

MISDEMEANOR

FELONY

PROBATION

PAROLE

OTHER

N/A

36. IF YOU HAVE HAD AND/OR PRESENTLY HAVE SUBSTANCE ABUSE ISSUES, PLEASE SELECT AND DESCRIBE BELOW:
DRUGS (Illicit)

ALCOHOL

DRUGS (Prescription)

OTHER

37. IF YOU HAVE A HISTORY OF OR ARE CURRENTLY IN ON-GOING TREATMENT(S) FOR SUBSTANCE ABUSE(S), PLEASE DESCRIBE BELOW:

39. DATE COMPLETED (MM/DD/YYYY)

38. DID ANYONE HELP YOU COMPLETE THIS FORM?
YES

NO

PROTECTION OF PRIVACY INFORMATION STATEMENT
(For use by counselees and rehabilitation program participants)
I have been informed and understand that the information requested in this and any later interviews is requested under the authorization of Title 38,
United States Code, 1.576, Veterans Benefits. This information is needed to assist in vocational and educational planning, to authorize my receipt of
rehabilitation services, to develop a record of my vocational progress, and to assure I obtain the best results from my rehabilitation program. I
understand that the information I provide will not be used for any other purpose and that my responses may be disclosed outside the VA only if the
disclosure is authorized under the Privacy Act of 1974, including the routine uses identified in VA system of records, 58VA21/22/28, Compensation,
Pension, Education, and Vocational Rehabilitation and Employment Records-VA, published in the Federal Register. Generally, disclosures under the
authority of a routine use will be made to develop my claim for vocational rehabilitation benefits under title 38, United States Code.
My giving the requested information is voluntary. I understand that the following results might occur if I do not give this information:
(1) I may not receive the maximum benefit either from counseling or from my education or rehabilitation program.
(2) If certain information is required before I may enter a VA program, my failure to give the information may result in my not receiving the education
or rehabilitation benefit for which I have applied.
(3) If I am in a program in which information on my progress is required, my failure to give this information may result in my not receiving further
benefits or services.
My failure to give this information will not have a negative effect on any other benefit to which I may be entitled.

I HEREBY CERTIFY THAT the information I have given above is true and correct to the best of my knowledge and belief. I realize that making
willful false statements concerning a material fact in a claim of Chapter 31 benefits is a punishable offense that may result in fine or imprisonment, or
both. (Reference: 38 U.S.C. 3802(a))
SIGNATURE OF CLAIMANT

DATE SIGNED

PRIVACY ACT INFORMATION: The responses you submit are considered confidential (38 U.S.C. 5701). Your obligation to respond is required in order to obtain benefits.
VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title 38, Code of Federal
Regulations 1.576 for routine uses (i.e., civil or criminal law enforcement, congressional communications, epidemiological or research studies, the collection of money owed
to the United States, litigation in which the United States is a party or has an interest, the administration of VA programs and delivery of VA benefits, verification of identity and
status, and personnel administration) as identified in the VA system of records, 58VA21/22/28, Compensation, Pension, Education, and Vocational Rehabilitation and
Employment Records - VA, published in the Federal Register. Information that you furnish may be utilized in computer matching programs with other Federal or State
agencies for the purpose of determining your eligibility to receive VA benefits, as well as to collect any amount owed to the United States by virtue of your participation in any
benefit program administered by the Department of Veterans Affairs.
RESPONDENT BURDEN: This form is used to determine entitlement to Chapter 31 benefits (38 U.S.C. 3106). Title 38, United States Code allows us to ask for this
information. We estimate that you will need an average of 45 minutes to review the instructions, find the information, and complete this form. VA cannot conduct or sponsor a
collection of information unless a valid OMB control number is displayed. Valid OMB numbers can be located on the OMB Internet Page at www.reginfo.gov/public/do/
PRAMain. If desired, you can call 1-800-827-1000 to get information on where to send comments or suggestions about this form.
VA FORM 28-1902w, XXX XXXX

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