VR1838 Situational Assessment and Work Sample Report



Texas Workforce CommissionVocational Rehabilitation ServicesSituational Assessment and Work Sample Report FORMTEXT ? General Instructions FORMTEXT ?Follow the instructions below to complete this form. FORMTEXT ?Complete the form electronically (on the computer) and answer all questions. FORMTEXT ?Write summaries in paragraph form in clear, descriptive English. Leave no blanks. Enter N/A if not applicable. FORMTEXT ?Print the form, obtain inked signatures, and submit. FORMTEXT ?Make certain that all standards are met before submitting this form with an invoice for payment. FORMTEXT ?Note: Vocational Evaluations cannot be done remotely. FORMTEXT ? Provider Information FORMTEXT ? Provider: FORMTEXT ?????Service Authorization Number: FORMTEXT ?????Return Report To FORMTEXT ?Counselor Name: FORMTEXT ?????Fax: FORMTEXT ?????Address: FORMTEXT ?????Email: FORMTEXT ?????City: FORMTEXT ?????State: FORMTEXT ?????ZIP: FORMTEXT ?????Customer Information FORMTEXT ?Customer Name: FORMTEXT ?????Case ID: FORMTEXT ?????Customer Address: FORMTEXT ?????Date of Birth: FORMTEXT ?????City: FORMTEXT ?????State: FORMTEXT ??ZIP code: FORMTEXT ?????Primary contact number: ( FORMTEXT ???) FORMTEXT ?????Email: FORMTEXT ?????Situational Assessments FORMTEXT ?A situational assessment is conducted at three or more competitive integrated work sites within a business or industry setting in the FORMTEXT ? community. The vocational evaluator must observe the customer for a minimum of two hours per competitive integrated work site. FORMTEXT ? After the customer participates in the situational assessment, record responses to the questions below. FORMTEXT ?Situational Assessment Number 1 FORMTEXT ?Time spent: FORMTEXT ?????Business name: FORMTEXT ?????Business location: FORMTEXT ?????Describe the setting: FORMTEXT ?????Describe what you saw the customer do and list any skills he or she demonstrated: FORMTEXT ?????Describe the customer’s functional abilities and transferable skills observed during the assessment: FORMTEXT ?????Describe the customer’s functional limitations, challenges, and barriers observed during the assessment: FORMTEXT ?????Instructions for the table below:Record your observations for each item listed below as demonstrated by customer at the conclusion of the assessment. FORMTEXT ? FORMTEXT ?Scoring SkillsScoring is based on the level of instruction and prompting that was needed to demonstrate the skill. FORMTEXT ? The scores are described below. FORMTEXT ?Excellent—skill was independently demonstrated with no instruction needed. FORMTEXT ?Good—skill was demonstrated after 1 prompt or verbal instruction. FORMTEXT ?Fair—skill was demonstrated after 2 or more prompts, verbal instructions or required visual instruction. FORMTEXT ?Poor—skill required continuous prompting and instruction, or the skill could not be demonstrated. FORMTEXT ?Category FORMTEXT ? Poor FairGood ExcellentBehavior not observedAppropriate personal relations with supervisor FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Open and clear communication with supervisor on work site FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Comfortable interacting with supervisor FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Anxious interacting with supervisor FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Benefits from instruction from supervisor FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Cooperates with others on work tasks FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Understands and follows through on instructions FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Productivity is consistent FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Punctuality FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Grooming/Dress FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Motivation to perform tasks FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Maintains attention to tasks FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Recognizes difference between work, school, home, and recreation FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Appropriate relations with co-workers FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Works well with co-workers FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Accepts unpleasant tasks FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Organizes work FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Initiates work independently FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Adapts to change in the work setting FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Shows ability to learn FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Frustration tolerance FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Aware of workplace rules and safety rules and precautions FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Inappropriate work behaviors FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Additional comments: FORMTEXT ?????Situational Assessment Number 2 FORMTEXT ?Time spent: FORMTEXT ?????Business name: FORMTEXT ?????Business location: FORMTEXT ?????Describe the setting: FORMTEXT ?????Describe what you saw the customer do and list any skills he or she demonstrated: FORMTEXT ?????Describe the customer’s functional abilities and transferable skills observed during the assessment: FORMTEXT ?????Describe the customer’s functional limitations, challenges, and barriers observed during the assessment: FORMTEXT ?????Instructions for the table below:Record your observations for each item listed below as demonstrated by customer at the conclusion of the assessment. FORMTEXT ? FORMTEXT ?Scoring SkillsScoring is based on the level of instruction and prompting that was needed to demonstrate the skill. FORMTEXT ? The scores are described below. FORMTEXT ?Excellent—skill was independently demonstrated with no instruction needed. FORMTEXT ?Good—skill was demonstrated after 1 prompt or verbal instruction. FORMTEXT ?Fair—skill was demonstrated after 2 or more prompts, verbal instructions or required visual instruction. FORMTEXT ?Poor—skill required continuous prompting and instruction, or the skill could not be demonstrated. FORMTEXT ?Category FORMTEXT ? Poor FairGood ExcellentBehavior not observedAppropriate personal relations with supervisor FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Open and clear communication with supervisor on work site FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Comfortable interacting with supervisor FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Anxious interacting with supervisor FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Benefits from instruction from supervisor FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Cooperates with others on work tasks FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Understands and follows through on instructions FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Productivity is consistent FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Punctuality FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Grooming/Dress FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Motivation to perform tasks FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Maintains attention to tasks FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Recognizes difference between work, school, home, and recreation FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Appropriate relations with co-workers FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Works well with co-workers FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Accepts unpleasant tasks FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Organizes work FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Initiates work independently FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Adapts to change in the work setting FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Shows ability to learn FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Frustration tolerance FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Aware of workplace rules and safety rules and precautions FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Inappropriate work behaviors FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Additional comments: FORMTEXT ?????Situational Assessment Number 3 FORMTEXT ?Time spent: FORMTEXT ?????Business name: FORMTEXT ?????Business location: FORMTEXT ?????Describe the setting: FORMTEXT ?????Describe what you saw the customer do and list any skills he or she demonstrated: FORMTEXT ?????Describe the customer’s functional abilities and transferable skills observed during the assessment: FORMTEXT ?????Describe the customer’s functional limitations, challenges, and barriers observed during the assessment: FORMTEXT ?????Instructions for the table below:Record your observations for each item listed below as demonstrated by customer at the conclusion of the assessment. FORMTEXT ? FORMTEXT ?Scoring SkillsScoring is based on the level of instruction and prompting that was needed to demonstrate the skill. FORMTEXT ? The scores are described below. FORMTEXT ?Excellent—skill was independently demonstrated with no instruction needed. FORMTEXT ?Good—skill was demonstrated after 1 prompt or verbal instruction. FORMTEXT ?Fair—skill was demonstrated after 2 or more prompts, verbal instructions or required visual instruction. FORMTEXT ?Poor—skill required continuous prompting and instruction, or the skill could not be demonstrated. FORMTEXT ?Category FORMTEXT ? Poor FairGood ExcellentBehavior not observedAppropriate personal relations with supervisor FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Open and clear communication with supervisor on work site FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Comfortable interacting with supervisor FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Anxious interacting with supervisor FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Benefits from instruction from supervisor FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Cooperates with others on work tasks FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Understands and follows through on instructions FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Productivity is consistent FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Punctuality FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Grooming/Dress FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Motivation to perform tasks FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Maintains attention to tasks FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Recognizes difference between work, school, home, and recreation FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Appropriate relations with co-workers FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Works well with co-workers FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Accepts unpleasant tasks FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Organizes work FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Initiates work independently FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Adapts to change in the work setting FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Shows ability to learn FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Frustration tolerance FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Aware of workplace rules and safety rules and precautions FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Inappropriate work behaviors FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Additional comments: FORMTEXT ?????Work Samples FORMTEXT ?A minimum of four Work Samples that were not completed in the vocational evaluation must be completed. FORMTEXT ? Work samples provide a close simulation of an actual industrial task, business operation, or component of an occupational area. FORMTEXT ? After the customer participates in the work sample, record responses to the questions below. FORMTEXT ?Work Sample Number 1 FORMTEXT ?Time spent: FORMTEXT ?????Business or Industry Type: FORMTEXT ?????Testing Environment: FORMTEXT ?????Describe what you saw the customer do and list any skills he or she demonstrated: FORMTEXT ?????Instructions for the table below:Record your observations for each item listed below as demonstrated by customer at the conclusion of the assessment. FORMTEXT ? FORMTEXT ?Scoring SkillsScoring is based on the level of instruction and prompting that was needed to demonstrate the skill. FORMTEXT ? The scores are described below. FORMTEXT ?Excellent—skill was independently demonstrated with no instruction needed. FORMTEXT ?Good—skill was demonstrated after 1 prompt or verbal instruction. FORMTEXT ?Fair—skill was demonstrated after 2 or more prompts, verbal instructions or required visual instruction. FORMTEXT ?Poor—skill required continuous prompting and instruction, or the skill could not be demonstrated. FORMTEXT ?Category FORMTEXT ? Poor FairGood ExcellentBehavior not observedAccepted instruction regarding the work sample FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Ability to follow 2 step directions FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Ability to follow multi-step directions FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Learned without extra instruction FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Learned with extra instruction FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Demonstrated aptitude for skill FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Demonstrated aptitude for task FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Performed task without assistance FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Performed task with assistance FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Demonstrated interest in task FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Demonstrated dislike of task FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Work product met expectations FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Production time met expectations FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Task would be appropriate job task FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Describe the customer’s functional limitations, challenges, and barriers observed during work sample. FORMTEXT ?????Additional comments: FORMTEXT ?????Work Sample Number 2 FORMTEXT ?Time spent: FORMTEXT ?????Business or Industry Type: FORMTEXT ?????Testing Environment: FORMTEXT ?????Describe what you saw the customer do and list any skills he or she demonstrated: FORMTEXT ?????Instructions for the table below:Record your observations for each item listed below as demonstrated by customer at the conclusion of the assessment. FORMTEXT ? FORMTEXT ?Scoring SkillsScoring is based on the level of instruction and prompting that was needed to demonstrate the skill. FORMTEXT ? The scores are described below. FORMTEXT ?Excellent—skill was independently demonstrated with no instruction needed. FORMTEXT ?Good—skill was demonstrated after 1 prompt or verbal instruction. FORMTEXT ?Fair—skill was demonstrated after 2 or more prompts, verbal instructions or required visual instruction. FORMTEXT ?Poor—skill required continuous prompting and instruction, or the skill could not be demonstrated. FORMTEXT ?Category FORMTEXT ? Poor FairGood ExcellentBehavior not observedAccepted instruction regarding the work sample FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Ability to follow 2 step directions FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Ability to follow multi-step directions FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Learned without extra instruction FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Learned with extra instruction FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Demonstrated aptitude for skill FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Demonstrated aptitude for task FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Performed task without assistance FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Performed task with assistance FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Demonstrated interest in task FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Demonstrated dislike of task FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Work product met expectations FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Production time met expectations FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Task would be appropriate job task FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Describe the customer’s functional limitations, challenges, and barriers observed during work sample. FORMTEXT ?????Additional comments: FORMTEXT ?????Work Sample Number 3 FORMTEXT ?Time spent: FORMTEXT ?????Business or Industry Type: FORMTEXT ?????Testing Environment: FORMTEXT ?????Describe what you saw the customer do and list any skills he or she demonstrated: FORMTEXT ?????Instructions for the table below:Record your observations for each item listed below as demonstrated by customer at the conclusion of the assessment. FORMTEXT ? FORMTEXT ?Scoring SkillsScoring is based on the level of instruction and prompting that was needed to demonstrate the skill. FORMTEXT ? The scores are described below. FORMTEXT ?Excellent—skill was independently demonstrated with no instruction needed. FORMTEXT ?Good—skill was demonstrated after 1 prompt or verbal instruction. FORMTEXT ?Fair—skill was demonstrated after 2 or more prompts, verbal instructions or required visual instruction. FORMTEXT ?Poor—skill required continuous prompting and instruction, or the skill could not be demonstrated. FORMTEXT ?Category FORMTEXT ? Poor FairGood ExcellentBehavior not observedAccepted instruction regarding the work sample FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Ability to follow 2 step directions FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Ability to follow multi-step directions FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Learned without extra instruction FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Learned with extra instruction FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Demonstrated aptitude for skill FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Demonstrated aptitude for task FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Performed task without assistance FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Performed task with assistance FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Demonstrated interest in task FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Demonstrated dislike of task FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Work product met expectations FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Production time met expectations FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Task would be appropriate job task FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Describe the customer’s functional limitations, challenges, and barriers observed during work sample. FORMTEXT ?????Additional comments: FORMTEXT ?????Work Sample Number 4 FORMTEXT ?Time spent: FORMTEXT ?????Time spent: FORMTEXT ?????Business or Industry Type: FORMTEXT ?????Testing Environment: FORMTEXT ?????Describe what you saw the customer do and list any skills he or she demonstrated: FORMTEXT ?????Instructions for the table below:Record your observations for each item listed below as demonstrated by customer at the conclusion of the assessment. FORMTEXT ? FORMTEXT ?Scoring SkillsScoring is based on the level of instruction and prompting that was needed to demonstrate the skill. FORMTEXT ? The scores are described below. FORMTEXT ?Excellent—skill was independently demonstrated with no instruction needed. FORMTEXT ?Good—skill was demonstrated after 1 prompt or verbal instruction. FORMTEXT ?Fair—skill was demonstrated after 2 or more prompts, verbal instructions or required visual instruction. FORMTEXT ?Poor—skill required continuous prompting and instruction, or the skill could not be demonstrated. FORMTEXT ?Category FORMTEXT ? Poor FairGood ExcellentBehavior not observedAccepted instruction regarding the work sample FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Ability to follow 2 step directions FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Ability to follow multi-step directions FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Learned without extra instruction FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Learned with extra instruction FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Demonstrated aptitude for skill FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Demonstrated aptitude for task FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Performed task without assistance FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Performed task with assistance FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Demonstrated interest in task FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Demonstrated dislike of task FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Work product met expectations FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Production time met expectations FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Task would be appropriate job task FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Describe the customer’s functional limitations, challenges, and barriers observed during work sample. FORMTEXT ?????Additional comments: FORMTEXT ?????Summary of Situational Assessments & Work Samples FORMTEXT ?Based on the information you have gathered, describe the type of jobs and/or FORMTEXT ? employment goal that would be the best employment setting for the customer. FORMTEXT ? Include job recommendations related to the current job market using the SOC codes for the customer’s geographical area. FORMTEXT ?????Based on the information you have gathered, describe the environment and work culture that would be the best employment setting for the customer. FORMTEXT ?????Based on the information you have gathered, what should be avoided to identify the best employment setting for the customer? FORMTEXT ?????Describe such supports as social, communication, learning, environmental, assistive technology, or other supports potentially necessary FORMTEXT ? to promote customer success in competitive integrated employment. FORMTEXT ?????Based on the situational assessments and work samples, would the customer most likely succeed in competitive integrated employment? FORMTEXT ?????If you do not recommend competitive integrated employment for the customer explain why. FORMTEXT ?????Provider Signatures FORMTEXT ?Vocational Evaluator Aide Signature (Required for anyone who assisted in administering the evaluation) FORMTEXT ?By signing below, I, the Vocational Evaluator Aide(s), certify that: FORMTEXT ? I maintain the staff qualifications required for a Vocational Evaluator Aide as described in the FORMTEXT ? TWC VR Standards for Providers or Service Authorization FORMTEXT ?; and worked under the supervision of the Vocational Evaluator. FORMTEXT ?Typed or Printed name: FORMTEXT ?????Signature: (See VR-SFP 3.11.1 Documentation and Signatures)X FORMTEXT ?Date Signed: FORMTEXT ?????Vocational Evaluator Signature (Required for all providers) FORMTEXT ?By signing below, I, the Vocational Evaluator, certify that: FORMTEXT ? the above dates, times, and services are accurate; FORMTEXT ?I remained onsite to supervise all services and vocational evaluator aides FORMTEXT ? maintaining the required ratios as stated in the TWC VR Standards for Providers; FORMTEXT ?a minimum of two hours and no more than six hours of assessment each day was provided; FORMTEXT ?I personally conducted/supervised the assessment and prepared this form; FORMTEXT ?all Outcomes Required for Payment, as described in the TWC VR Standards for Providers and Service Authorization(s) are met; FORMTEXT ?I and any aides maintain the staff qualifications required as described in the TWC VR Standards for Providers or Service Authorization; and FORMTEXT ?I signed my signature and entered the date below. FORMTEXT ? Typed or Printed name: FORMTEXT ?????Signature: (See VR-SFP 3.11.1 Documentation and Signatures)X FORMTEXT ?Date Signed: FORMTEXT ?????Director Credentials and Signature FORMTEXT ?By signing below, I, the Director, certify that: FORMTEXT ? I handwrote my signature and the date below;I ensure that the staff meets the qualifications and met the requirements in the Standards when delivering the service; and FORMTEXT ?I maintain the staff qualifications, including the UNTWISE credential, required for a Director, FORMTEXT ? as described in TWC VR Standards for Providers and/or Service Authorization. FORMTEXT ? QualificationsProof of QualificationVerified by TWS-VRSUNTWISE Director Credential: FORMTEXT ?UNTWISE Credential Number: FORMTEXT ????? if no, FORMCHECKBOX VR3490-Waiver Proof Attached FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/ATyped or Printed name: FORMTEXT ?????Signature: (See VR-SFP 3.11.1 Documentation and Signatures)X FORMTEXT ?Date Signed: FORMTEXT ?????VRS Use Only FORMTEXT ?If any question below is answered no or if the report or supporting documentation is missing or incomplete, return the invoice to the provider with the VR3460. Make a case note to document the results of the review and the date VR3460 was sent to provider, when applicable. FORMTEXT ? FORMTEXT ?Technical Review to Verify Provider Qualifications(Completed by any VR staff such as RA, CSC, VR Counselor) FORMTEXT ?Director’s Credential: FORMTEXT ?UNTWISE website or attached VR3490 verifies, for the dates of service, the director listed above: FORMTEXT ? FORMCHECKBOX maintained or waived the UNTWISE Director Credential FORMCHECKBOX did not hold a valid UNTWISE Director CredentialVerification of Service Delivery FORMTEXT ?Technical Review (completed by any VR staff such as RA, CSC, VR Counselor) FORMTEXT ?Verified that the report is accurately completed per form instructions FORMCHECKBOX Yes FORMCHECKBOX NoVerified that the service(s) was provided within service date of SA and as stated in the VR Standards for Providers and/or the SA FORMCHECKBOX Yes FORMCHECKBOX NoWhen applicable, verified a copy of an approved VR3472 is attached to the report. FORMCHECKBOX NA FORMCHECKBOX Yes FORMCHECKBOX NoVerified that a total of three Situational Assessments were completed in different work settings. FORMTEXT ? FORMCHECKBOX Yes FORMCHECKBOX NoVerified that the appropriate fee(s) was invoiced FORMCHECKBOX Yes FORMCHECKBOX NoPrint staff member(s) names who completed technical review and/or verified the UNTWISE Credentials: FORMTEXT ?1. FORMTEXT ????? Date: FORMTEXT ?????2. FORMTEXT ????? Date: FORMTEXT ?????VR Counselor Review FORMTEXT ?Verified that a total of four Work Samples were completed and were not the same Work Samples as completed on the Vocational Evaluation. FORMTEXT ? FORMCHECKBOX Yes FORMCHECKBOX NoVerified that the information in all sections of the form are unique and individualized for the customer. FORMTEXT ? FORMCHECKBOX Yes FORMCHECKBOX NoVerified that the form indicates specific training options that match the customer’s capabilities. FORMCHECKBOX Yes FORMCHECKBOX NoVerified that the vocational evaluator and/or aides collected information through customer observations held at multiple locations. FORMTEXT ? FORMCHECKBOX Yes FORMCHECKBOX NoBy typing or printing your name, the VRC verifies: FORMTEXT ?completion of the technical review, FORMTEXT ?services provided met the customer’s individual needs, FORMTEXT ?services provided met specifications in the VR-SFP and on the SA, and FORMTEXT ?customer’s or legally authorized representative’s satisfaction with services received. FORMTEXT ? FORMCHECKBOX Approve to pay invoice FORMCHECKBOX Do not approve to pay invoiceVR Counselor: FORMTEXT ????? Date: FORMTEXT ????? ................
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