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SB Forms

DSB Forms Guide (October 2019)xlsx24 KB
Criminal Record Check Consent Form (DHR-ESB-3004)pdf83 KB
Criminal Record Check Transmittal Form (DHR-ESB-3001)pdf94 KB
Employee Incident Reportpdf89 KB
Supervisor Incident Reportpdf197 KB
Witness Incident Reportpdf55 KB
dsb-4046-instructions: DSB/DSB Outreach Report Instructionspdf110 KB
dsb-4046-ia: DSB/DSB Outreach Reportpdf1 MB
dhhs-1000-DSB-instructions: DSB/Authorization to Disclose Health Information Instructionspdf148 KB
dhhs-1000-ia: DSB Authorization to Disclose Health Informationpdf382 KB
dhhs-1000-sp-ia: DSB/Authorization to Disclose Health Information-Spanishpdf392 KB
dhhs-3531 dsb-0910-ia: Conference Authorizationpdf556 KB
dsb-0197-ILR-ia: ILR Request for Residence Modificationpdf345 KB
dsb-0197-ILR-instructions: ILR/Request for Residence Modification Instructionspdf136 KB
dsb-0311: DSB/Employee Administration Request Formpdf75 KB
dsb-0502-ia: DSB/Travel Authorization and Training Registrationpdf579 KB
dsb-0502-instructions: DSB/Travel Authorization and Training Registration Instructionspdf156 KB
dsb-0503-ia: DSB/Driver Service Billing Formpdf353 KB
dsb-0511: DSB/Pharmacy Claim Formpdf571 KB
dsb-0511-instructions: DSB/Pharmacy Claim Form Instructionspdf135 KB
dsb-0525-DSB-instructions: DSB/DSB Accounts Receivable/Refund Instructionspdf133 KB
dsb-0525-ia: DSB/DSB Accounts Receivable/Refundpdf301 KB
dsb-0612-ia: DSB/Staff Approved to Authorize Services, Approve Authorizations, and/or Approved Invoicespdf509 KB
dsb-0613-VR-ia: VR/Assignment of Reimbursementpdf319 KB
dsb-0613-VR-instructions: VR/Assignment of Reimbursement Instructionspdf155 KB
dsb-0950-ia: DSB/Verification of Items Receivedpdf322 KB
dsb-0950-ia-instructions: DSB/Verification of Items Received Instructionspdf122 KB
dsb-1010-ia: Blind Registry/Registrant Data Formpdf1,005 KB
dsb-2001-ia: MED.EYE/Application for Eye Care Certificationpdf766 KB
dsb-2001-instructions: MED.EYE/Application for Eye Care Certification Instructionspdf113 KB
dsb-2007-ia: DSB/Evaluation with Video Magnification (Closed Circuit Television)pdf376 KB
dsb-2007-instructions DSB/Evaluation with Video Magnification (Closed Circuit Television) Instructionspdf146 KB
dsb-2031-ia: MED.EYE/Letter to Accompany Mailed Applicationpdf323 KB
dsb-2032-ia: MED.EYE/Notification of Need for Additional Informationpdf322 KB
dsb-2032-instructions: MED.EYE/Notification of Need for Additional Information Instructionspdf112 KB
dsb-2033-ia: MED.EYE/Notification of Eligibility Statuspdf338 KB
DSB/Report of Eye Examination Instructionspdf132 KB
dsb-2033-instructions: MED.EYE/Notification of Eligibility Status Instructionspdf129 KB
dsb-2202-ia: DSB/Report of Eye Examinationpdf542 KB
dsb-2205-A-ia: DSB/Referral for Low Vision Evaluationpdf339 KB
dsb-2205-A-instructions: DSB/Referral for Low Vision Evaluation Instructionspdf150 KB
dsb-2205-B-ia: DSB/Report on Low Vision Evaluationpdf305 KB
dsb-2207-ia; MED.EYE/Vision Screening Listpdf385 KB
dsb-2207-instructions: MED.EYE/Vision Screening List Instructionspdf112 KB
dsb-2218-ia: MED.EYE/Permission Form for Vision Screening at Day Carepdf312 KB
dsb-2218-instructions: MED.EYE/Permission Form for Vision Screening at Day Care Instructionspdf109 KB
dsb-2220-ia: MED.EYE/Report to Parents of Child Screened at Day Carepdf317 KB
dsb-2220-instructions: MED.EYE/Report to Parents of Child Screened at Day Care Instructionspdf116 KB
dsb-4002-AT-ILR-ia: ILR/Referral for Assistive Technology Servicespdf397 KB
dsb-4002-AT-ILR-instructions: ILR/Referral for Assistive Technology Services Instructionspdf124 KB
dsb-4002at-VR-ia: VR/Referral for Assistive Technology Servicespdf408 KB
dsb-4002at-VR-instructions: VR/Referral for Assistive Technology Services Instructionspdf132 KB
dsb-4002-ILR-ia: ILR/Referral Formpdf325 KB
dsb-4002-ILR-instructions ILR/Referral Form Instructionspdf130 KB
dsb-4002-VR-ia VR Referral Formpdf330 KB
dsb-4004b-ILR-ia: ILR/Independent Living Rehabilitation Agreement of Understanding with Applicant for Servicespdf330 KB
dsb-4004b-ILR-instructions: ILR/Independent Living Rehabilitation Agreement of Understanding with Applicant for Services Instructionspdf105 KB
dsb-4004-ILR-ia: ILR/Independent Living Rehabilitation Applicationpdf634 KB
dsb-4004-ILR-instructions: ILR/Independent Living Rehabilitation Application Instructionspdf157 KB
dsb-4004-VR-ia: VR/Rehabilitation Applicationpdf493 KB
dsb-4004-VR-instructions: VR/Rehabilitation Application Instructionspdf211 KB
dsb-4005a-handbook-VR: VR/Vocational Rehabilitation Handbookpdf81 KB
dsb-4005a-ILR: ILR/Independent Living Planpdf111 KB
dsb-4005a-VR-ia: VR/Agreement of Understanding with Applicant for Servicespdf323 KB
dsb-4005a-VR-instructions: VR/Agreement of Understanding with Applicant for Services Instructionspdf119 KB
dsb-4005b-cont-VR-ia: VR/Individualized Plan for Employment (Continuation Page-Services)pdf333 KB
dsb-4005b-cont-VR-instruction: VR/Individualized Plan for Employment (Continuation Page-Services) Instructionspdf125 KB
dsb-4005b-ILR-ia: ILR/Independent Living Planpdf335 KB
dsb-4005b-ILR-instructions: ILR/Independent Living Plan Instructionspdf120 KB
dsb-4005b-VR-ia: VR/Individualized Plan for Employmentpdf353 KB
dsb-4005b-VR-instructions: VR/Individualized Plan for Employment Instructionspdf165 KB
dsb-4005c-ILR-ia: ILR/Independent Living Plan Continuation Pagepdf319 KB
dsb-4005c-ILR-instructions: ILR/Independent Living Plan Continuation Page Instructionspdf112 KB
dsb-4005c-VR-ia: VR/Individualized Plan for Employment Closure Amendmentpdf336 KB
dsb-4005c-VR-instructions: VR/Individualized Plan for Employment Closure Amendment Instructionspdf166 KB
dsb-4005d-ILR-ia: ILR/Independent Living Plan Amendmentpdf326 KB
dsb-4005d-ILR-instructions: ILR/Independent Living Plan Amendment Instructionspdf150 KB
dsb-4005d-VR-ia: VR/Individualized Plan for Employment Amendmentpdf340 KB
dsb-4005d-VR-instructions: VR/Individualized Plan for Employment Amendment Instructionspdf162 KB
dsb-4005e: DSB/Code of Conductpdf217 KB
dsb-4005-ILR-ia: ILR/Independent Living Closure Amendmentpdf331 KB
dsb-4005-ILR-instructions: ILR/Independent Living Closure Amendment Instructionspdf121 KB
dsb-4008sub-VR-AW: VR/Waiver for Documenting Refusal of Services Required of Section 511 (25+ Years Old)docx109 KB
dsb-4008sub-VR-C: VR/Certificate of Completiondocx108 KB
dsb-4008sub-VR-DOC: VR/Record of Transition & PETS Services Receiveddocx113 KB
dsb-4008sub-VR-IR: VR/Information and Referral Services Reportdocx107 KB
dsb-4008sub-VR-YW: VR/Waiver for Documenting Refusal of Services Required of Section 511 (Youth Age 14-24)docx109 KB
dsb-4009ojt-m-VR-ia: VR/Modified On-The-Job Training Agreementpdf333 KB
dsb-4009ojt-m-VR-instructions: VR/Modified On-The-Job Training Agreement Instructionspdf161 KB
dsb-4009ojt-VR-ia: VR/On-The-Job Training Agreement Instructionspdf160 KB
dsb-4009ojt-pr-VR-ia: VR/On-The-Job Training (OJT) Progress Reportpdf333 KB
dsb-4009ojt-pr-VR-instructions VR/On-The-Job Training (OJT) Progress Report Instructionspdf128 KB
dsb-4009ojt-VR-ia: VR/On-The-Job Training Agreementpdf333 KB
dsb-4009ojt-wrap-VR-ia: VR/On-The-Job Training Agreement Wage Reimbursement for Advanced Placementpdf332 KB
dsb-4009ojt-wrap-VR-instructions: VR/On-The-Job Training Agreement Wage Reimbursement for Advanced Placement Instructionspdf163 KB
dsb-4009wcc-a-VR-ia: VR/Request for Workers’ Compensation Coveragepdf323 KB
dsb-4009wcc-a-VR-instructions: VR/Request for Workers’ Compensation Coverage Instructionspdf126 KB
dsb-4009wcc-b-VR-ia: VR/Rehabilitation Individual Report of Injurypdf318 KB
dsb-4009wcc-b-VR-instructions: VR/Rehabilitation Individual Report of Injury Instructionspdf125 KB
dsb-4009wcc-c-VR-ia: VR/Rehabilitation Individual Incident Investigation Reportpdf331 KB
dsb-4009wcc-c-VR-instructions: VR/Rehabilitation Individual Incident Investigation Report Instructionspdf134 KB
dsb-4009wcc-d-VR-ia: VR/Rehabilitation Individual Workers’ Compensation Medical Authorizationpdf355 KB
dsb-4009wcc-d-VR-instructions: VR/Rehabilitation Individual Workers’ Compensation Medical Authorization Instructionspdf99 KB
dsb-4009wop-VR-ia: VR/Agreement for Work Experience without Paypdf355 KB
dsb-4009wop-VR-instructions: VR/Agreement for Work Experience without Pay Instructionspdf154 KB
dsb-4011-ILR-ia: ILR/Case Progress Notespdf300 KB
dsb-4011-ILR-instructions: ILR/Case Progress Notes Instructionspdf121 KB
dsb-4011-VR-ia: VR/Case Progress Notespdf300 KB
dsb-4011-VR-instructions: VR/Case Progress Notes Instructionspdf124 KB
dsb-4016a-ILR-ia: ILR/Equipment and Computer Use Agreementpdf344 KB
dsb-4016a-ILR-instructions: ILR/Equipment and Computer Use Agreement Instructionspdf141 KB
dsb-4016-ia: DSB/Equipment and Computer Use Agreementpdf353 KB
dsb-4016-instructions: DSB/Equipment and Computer Use Agreement Instructionspdf155 KB
dsb-4017-ILR-ia: ILR/Authorization to Disclose Independent Living Rehabilitation Informationpdf552 KB
dsb-4017-ILR-instructions: ILR/Authorization to Disclose Independent Living Rehabilitation Information Instructionspdf123 KB
dsb-4017-VR-ia: VR/Authorization to Disclose Vocational Rehabilitation Informationpdf355 KB
dsb-4017-VR-instructions: VR/Authorization to Disclose Vocational Rehabilitation Information Instructionspdf124 KB
dsb-4020-ia: DSB/Pharmacy Agreementpdf336 KB
dsb-4033a-ILR-ia: ILR/ILOB Travel Reimbursement for Mini Center Instructorspdf960 KB
dsb-4033a-ILR-instructions: ILR/ILOB Travel Reimbursement for Mini Center Instructors Instructionspdf921 KB
dsb-4033b-ILR-ia: ILR/Billing for Mini Center Instructorspdf985 KB
dsb-4033b-ILR-instructions: ILR/Billing For Mini Center Instructors Instructionspdf115 KB
dsb-4033-VR-ia: VR/Billing for Reader Servicepdf543 KB
dsb-4033-VR-instructions: VR/Billing for Reader Service Instructionspdf128 KB
dsb-4040-ia: VR/ILR Financial Needs Surveypdf600 KB
dsb-4040-instructions: VR/ILR Financial Needs Survey Instructionspdf183 KB
dsb-4041-VR-ia: VR/Extension of Time to Determine Eligibilitypdf316 KB
dsb-4041-VR-instructions: VR/Extension of Time to Determine Eligibility Instructionspdf126 KB
dsb-4042-ILR-ia: ILR/Authorization to Photograph/Use Photograph/Interviewpdf333 KB
dsb-4042-ILR-instructions: ILR/Authorization to Photograph/Use Photograph/Interview Instructionspdf153 KB
dsb-4042-VR-ia: VR/Authorization to Photograph/Use Photograph/Interviewpdf343 KB
dsb-4042-VR-instructions: VR/Authorization to Photograph/Use Photograph/Interview Instructionspdf119 KB
dsb-4043-ia: ILS/Mini-Center Mobility Reportpdf351 KB
dsb-4044-VR-ia: VR/Deaf Blind Assessmentpdf873 KB
dsb-4044-VR-instructions: VR/Deaf Blind Assessment Instructionspdf156 KB
dsb-4045-ILR-ia: ILR/Health Check Listpdf449 KB
dsb-4045-ILR-instructions: ILR/Health Check List Instructionspdf138 KB
dsb-4045-VR-ia: VR/Health Check Listpdf452 KB
dsb-4045-VR-instructions: VR/Health Check List Instructionspdf141 KB
dsb-4047a-VR-ia: VR/Low Vision Eye Doctor Evaluation Report Addendumpdf294 KB
dsb-4047-VR-ia: VR/Low Vision Eye Doctor Evaluation Reportpdf410 KB
dsb-4048b-ia: DSB/Agreement to Purchase Bioptics for Non-Driving Purposespdf515 KB
dsb-4048-ia: DSB/Hearing Aid Agreementpdf362 KB
dsb-4048-instructions: DSB/Hearing Aid Agreement Instructionspdf336 KB
dsb-4049-ILR-ia: ILR/Independent Living Rehabilitation Counselor II Evaluationpdf654 KB
dsb-4049-VR-ia: VR/Vocational Rehabilitation Counselor II Evaluationpdf654 KB
dsb-4050-ILR-ia: ILR/Mini Center Narrativepdf323 KB
dsb-4050-ILR-instructions: ILR/Mini Center Narrative Instructionspdf111 KB
dsb-4051-ILR-ia: ILR/Independent Living Mini Center Surveypdf335 KB
dsb-4051-ILR-instructions: ILR/Independent Living Mini Center Survey Instructionspdf111 KB
dsb-4052-ILR-ia: ILR/Mini Center Instructor Evaluation Formpdf383 KB
dsb-4052-ILR-instructions: ILR/Mini Center Instructor Evaluation Form Instructionspdf113 KB
dsb-4054-ILR-ia: ILR/ILR Administrative P-Card Purchase Justificationpdf329 KB
dsb-4054-ILR-instructions: ILR/ILR Administrative P-Card Purchase Justification Instructionspdf110 KB
dsb-4056-VR-ia: VR/Transition Technology Loan Agreementpdf328 KB
dsb-4056-VR-instructions: VR/Transition Technology Loan Agreement Instructionspdf165 KB
dsb-4057-ILR-ia: ILR/Mini Center Instructor Applicationpdf94 KB
dsb-4058-VR-ia: VR/Transportation Servicespdf360 KB
dsb-4058-VR-instructions: VR/Transportation Services Instructionspdf131 KB
dsb-5056-BE-ia: BE/Training Evaluationpdf203 KB
dsb-5056-BE-instructions: BE/Training Evaluation Instructionspdf98 KB
dsb-5057-BE-ia: BE/On-The-Job Training Checklist for Levels I & IIpdf408 KB
dsb-5057-BE-instructions: BE/On-The-Job Training Checklist for Levels I & II Instructionspdf118 KB
dsb-5058-BE: BE/On-The-Job Training Guide For Levels I & IIpdf130 KB
dsb-5064-BE-ia: BE/On-The-Job Training Agreementpdf326 KB
dsb-5064-BE-instructions: BE/On-The-Job Training Agreement Instructionspdf97 KB
dsb-5065-BE-ia: BE/On-The-Job Trainer Invoicepdf160 KB
dsb-5065-BE-instructions: BE/On-The-Job Trainer Invoice Instructionspdf99 KB
dsb-7001-ia: ILS/Independent Living Services Program Applicationpdf389 KB
dsb-7080-ia: ILS/Cane Request Formpdf362 KB
dsb-7103-B-ia: ILS/Orientation and Mobility Service Planpdf560 KB
dsb-7103-ia: ILS/Independent Living Services Program Assessment and Planpdf435 KB
dsb-7103-instructions: ILS/Independent Living Services Program Assessment and Plan Instructionspdf139 KB
dsb-7108-ia: ILS/Agreement for In-Home Aide Services: Level I- Home Managementpdf354 KB
dsb-7219-ia: ILS & MED.EYE/Application for Conferencepdf307 KB
dsb-7219-instructions: ILS & MED.EYE/Application for Conference Instructionspdf115 KB
dsb-7222: SAB/dsb-7222pdf38 KB
dsb-7223: SAB/dsb-7223pdf39 KB
dsb-7224: SAB/dsb-7224pdf39 KB
dsb-7225: SAB/dsb-7225pdf34 KB
dsb-7309-ia: ILS/Time Log for In-Home Service (Level I-Home Management)pdf379 KB
dsb-7311-ia: ILS/Training Record for In-Home Aide (Level I-Home Management)pdf332 KB
dsb-7399-ia: ILS/Forms Requestpdf330 KB
dsb-7401-ILR-ia: ILR/Independent Living Eligibility Certificationpdf331 KB
dsb-7401-ILR-instructions: ILR/Independent Living Eligibility Certification Instructionspdf119 KB
dsb-7402-ILR-ia: ILR/Independent Living Plan Waiverpdf306 KB
dsb-7402-ILR-instructions: ILR/Independent Living Plan Waiver Instructionspdf114 KB
dsb-7403-VR-ia: VR/Internship/Traineeship Agreementpdf340 KB
dsb-7403-VR-instructions: VR/Internship/Traineeship Agreement Instructionspdf168 KB
dsb-7404-ia: ILS/Notice: White Support Canepdf106 KB
dsb-7405-ia: DSB/Confidentiality Statement for Driverspdf301 KB
dsb-7406-ia: DSB/Code of Conduct Violation Incident Reportpdf299 KB
dsb-7407-ia: DSB/Code of Conduct Violation Investigation Reportpdf319 KB
dsb-DrivingRecordStatus-ia: DSB/Driving Record Status Formpdf316 KB
FNS_ILS_2-2016: DSB ILS Financial Needs Surveypdf566 KB
FNS_MEC_2-2016: DSB MEC Financial Needs Surveypdf560 KB
HCFA-1500: MED.EYE/Health Insurance Claim Formpdf92 KB
HCFA-1500-instructions: MED.EYE/Health Insurance Claim Form Instructionspdf1 MB
IRS-2678-DSB-Instructions: DSB/Employer Appointment of Agent Instructionspdf137 KB
IRS-2678-ia: Employer/Payer Appointment of Agentpdf81 KB
IRS-I-9-DSB-Instructions: Employment Eligibility Verification Instructionspdf112 KB
IRS-I-9-ia Form I-9 Employment Eligibility Verificationpdf372 KB
IRS-W-9-DSB-Instructions: Request for Taxpayer Identification Number and Certification Instructionspdf139 KB
irs-w-9-ia: DSB/Request for Taxpayer Identification Number and Certificationpdf250 KB
DSB/North Carolina Voter Registration Applicationpdf853 KB
DSB/NC Voter Registration Agency Transmittal Formpdf47 KB
DSB/NC Voter Registration Preference Form- Spanishpdf200 KB
DSB/NC Voter Registration Supplies Order Formpdf95 KB
DSB/Payment Verification Formpdf266 KB
PD-136-DSB-instructions: DSB/Application for Academic Assistance Instructionspdf144 KB
PD-136-ia: DSB/Application for Academic Assistancepdf79 KB
DSB/Request Prior Approval Claim Form for Eyeglassespdf168 KB
New Hanover County Special Needs Registration Formpdf360 KB
NC DHHS Teacher Evaluation Process Pre-Observationpdf32 KB
NC DHHS Teacher Evaluation Process Timelinepdf35 KB
NC DHHS Teacher Individual Growth Planpdf49 KB
NC DHHS Teacher Summary Rating Formpdf65 KB
NC Teacher Evaluation Process for DHHSpdf103 KB
Teacher Certification Rubric for Evaluating DHHS Teacherspdf430 KB
Teacher Certification Rubric for Evaluating NC Teacherspdf220 KB
Teacher Certification Teacher Observation Formpdf48 KB
Teacher Certification Post-Observation Conference Documentationpdf25 KB
Use of Leave Options Formpdf39 KB