Forms and instructions used by the Division of Blind Services, Department of Labor and Employment Security, in its dealings with the public are prescribed and listed below. These forms and instructions are hereby incorporated and made a part of this rule. A copy of any form may be obtained without cost upon request to the Division of Blind Services, Department of Labor and Employment Security, 2540 Executive Center Circle, West, Suite 203, Tallahassee, FL 32399-2950. When requesting a specific form, reference should be made to the form number and title.

DBS-001 (7/81)
Referral and Application for Services (Florida Statutes § 413.011)

DBS-002 (7/81)
Application for Identification Card (Florida Statutes § 413.091)

DBS-003 (7/81)
Physician’s Report on Eye Condition (Florida Statutes § 413.011)

DBS-004 (7/81)
General Medical Examination Report (Florida Statutes § 413.011)

DBS-005 (7/81)
Case Summary For Medical Consultant (Florida Statutes § 413.011)

DBS-006 (7/81)
Final Report on Result of Operation Sight Restoration or Prevention of Blindness (Florida Statutes § 413.011)

DBS-007 (8/81)
Application for Services Based on Economic Need (Florida Statutes § 413.011)

DBS-008 (7/81)
Referral to Rehabilitation Facility (Florida Statutes § 413.011)

DBS-009 (7/81)
Dental Examination Report (Florida Statutes § 413.011)

DBS-010 (7/81)
Referral to Eye Clinic (Florida Statutes § 413.011)

DBS-011 (7/81)
Client Transportation (Florida Statutes § 413.011)

DBS-016 (8/81)
Invoice for Glasses (Florida Statutes § 413.011)

DBS-017 (11/81)
Consent for Release of Information (Florida Statutes § 413.011)

DBS-022 (4/82)
Facility Expenditure Report (Florida Statutes § 413.011)

DBS-023 (4/82)
Facility Utilization Report (Florida Statutes § 413.011)

DBS-100 (12/81)
Authorization and Billing Invoice (Client Services Vocational Rehabilitation Program) (Florida Statutes § 413.011)

DBS-101 (7/81)
Individualized Written Rehabilitation Program (Florida Statutes § 413.011)

DBS-101a (7/81)
Individualized Written Rehabilitation Program – Service Agreement (Florida Statutes § 413.011)

DBS-103 (5/82)
Referral for Vocational Rehabilitation (Florida Statutes § 413.011)

DBS-104 (7/81)
Client Service Log (Florida Statutes § 413.011)

DBS-106 (12/81)
Training Progress Report (Florida Statutes § 413.011)

DBS-107 (7/81)
Maintenance Invoice (Florida Statutes § 413.011)

DBS-108 (8/82)
Client Equipment Receipt & Inventory Record (Florida Statutes § 413.011)

DBS-200 (12/81)
Authorization and Billing Invoice (Client Services Medical and Social Services Program) (Florida Statutes § 413.011)

DBS-201 (7/81)
Medical and Social Services Rehabilitation Plan (Florida Statutes § 413.011)

DBS-203 (7/81)
Application for Preschool Program (Florida Statutes § 413.011)

DBS-210 (7/81)
Title XX – Right to Appeal (Florida Statutes § 413.011)

DBS-501 (3/83)
Notice of Appointment (Florida Statutes § 413.011)

DBS-502 (3/83)
Certification of Legal Blindness Notice (Florida Statutes § 413.011)

DBS-503 (3/83)
Notice of Missed Appointment (Florida Statutes § 413.011)

DBS-701 (10/81)
Monthly Supervision Report (Florida Statutes § 413.051)

DBS-703 (10/81)
Employee Personal Data (Florida Statutes § 413.051)

DBS-704 (10/81)
Drivers License (Turn-in) Form (Florida Statutes § 413.011)

DBS-706 (10/81)
Statement of Written Guidelines (Florida Statutes § 413.051)

DBS-710 (10/81)
Petty Cash Receipt (Florida Statutes § 413.051)
Rulemaking Authority 20.05(1), 20.15(7), 120.53(1)(b), 229.053(1), 413.011(1)(m) FS. Law Implemented 20.05(1), 20.15(7), 120.53(1)(b), 413.011, 413.051, 413.091 FS. History-New 6-28-83, Formerly 6A-18.15, 6A-18.015, 38K-1.015.