DARS - Division for Rehabilitation Services Self Screening Tool

Do you want to go to work or keep your job? Yes No

Would you like someone to contact you about our services? Yes No

How do you think we can assist you?

What is the best way to contact you? (Entries marked with an asterisk are required) Mail Telephone Email

*Name:

*Address:

*City:

*State:

*ZIP:

*Email:

*Phone:

DRS Vocational Rehabilitation Self Screening Tool