Disability Related Employment Needs Assessment (DRENA)

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Disability Related Employment Needs Assessment (DRENA)

Personal information collected on this form is collected under the authority of Section 26 (c) of the Freedom of Information and Protection of Privacy Act (FOIPPA) and is subject to all of the provisions of that Act. The personal information collected will be used by the Ministry of Social Development and Poverty Reduction, its service providers and associates of those service providers to publicize and promote WorkBC Employment Services, WorkBC Assistive Technology Services or WorkBC Apprentice Services, as applicable. If you have any questions about the collection of your personal information, please contact:
Name of contact for questions about the collection of personal information.
Address of contact for questions about the collection of personal information.
(555) 555-5555 Telephone number of contact for questions about the collection of personal information.

Client Information

Client's Last Name
Client's First Name
Client's Street Address
Client's City/town
Client's Province
Client's Postal Code (A1A 1A1)
(555) 555-5555 Client's Telephone Number
Client's E-mail Address

Primary Disability Information

Congenital
Acquired
If the primary disability was acquired, the date of onset was (MM/DD/YYYY)
Permanent
Cycling/Recurrent
Documented (Medically Verified)
Current Accommodations

Other Disability Information

Congenital
Acquired
If the other disability was acquired, the date of onset was (MM/DD/YYYY)
Permanent
Cycling/Recurrent
Documented (Medically Verified)
Current Accommodations

Confirmation of Disability

Select all that apply:

Previously Completed Assessments

Date of assessment (MM/DD/YYYY):

Disability Details (Self-Reporting)

Employment-Related Disability Impacts

Employment-Related Disability Needs Summary

Specialized Assessment Services

Recommended Accommodations and Ideal Working Conditions

Work Routine
Examples include: consistent schedule, flexible schedule, flexible work hours, longer or more frequent work breaks, part-time schedule, periodic rest breaks, work from home and other.
Physical Work Environment
Examples include: information in large print, mirrors to communicate presence of others, natural or full spectrum lighting, scent free environment, temperature controlled work environment, use of fan at work station, worksite with minimal extraneous noises and other.
Accessibility
Examples include: accessible office space (washroom, lunchroom, automatic doors), accessible parking, assistive devices, equipment, or technology, auditory versions of printed documents, braille formatted documents, communication or hearing devices, ergonomic supports, interpreter, note taker, restorative supports, signs to indicate hearing loss/need for communication to be direct or in writing, use of an attendant, use of guide dog and other.
Learning Supports
Examples include: additional time to learn new responsibilities, assistance with prioritizing assignments, consistent tasks, email or instant messaging, not phone, extra time for training, learning new tasks, modified work load and tasks, reminder system, self-paced work load, task check list, visual aids for tasks and location of items, worksite buddy system, written instructions/ communication and other.
Interpersonal Supports
Examples include: headset (music, white noise), minimal distractions, minimal to no workplace stress, ongoing reassurance and feedback regarding work performance, telephone calls during work hours for support, appointments, relapse prevention, work behind the scene – not directly with public, work independently and other.
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