VR1644 Supported Employment Services Time Tracking Log
Texas Workforce CommissionVocational Rehabilitation ServicesSupported Employment ServicesTime Tracking Log FORMTEXT ?Customer Identification FORMTEXT ?Customer name: FORMTEXT ?????VRS Case ID: FORMTEXT ?????Associated service authorization number: FORMTEXT ?????Benchmark Information FORMTEXT ?Indicate at each submission one benchmark or reason the form is being completed: FORMCHECKBOX Benchmark 2 FORMCHECKBOX Benchmark 3 FORMCHECKBOX Benchmark 4 FORMCHECKBOX Benchmark 5 FORMCHECKBOX Benchmark 6 FORMCHECKBOX Other (explain): FORMTEXT ?????Customer’s Employment Information FORMTEXT ? Customer’s job title: FORMTEXT ?????Customer’s first day of paid employment (first day worked: month/day/year): FORMTEXT ?????Hours Worked by the Customer FORMTEXT ?Instructions for completing this form can be found at: (insert hyperlink)For each week the customer worked, enter the date (mm/dd/yy) of 1st day of employer’s defined work week FORMTEXT ? through the last day of the employer’s defined work week in the date column. FORMTEXT ?For each day of the week, record the number of hour(s) the customer worked for the employer earning a wage and FORMTEXT ? enter the total number of hours worked each week. FORMTEXT ? If customer is absent from work, record an “A” for the day missed FORMTEXT ? and indicate the reason for the absence in comment section. FORMTEXT ? If the customer begins employment in the middle of the employer’s work week, the days worked can count toward the 5 FORMTEXT ? days/shifts as long as all other nonnegotiable hours/shifts criteria are met. FORMTEXT ? Indicate if the days in week are eligible to be counted. To be eligible, the customer must have worked the required number of hours FORMTEXT ? prescribed in the employment conditions and not had a 7 day or greater break in a work week FORMTEXT ? (absences or employer has not scheduled the customer to work) in work at job site. FORMTEXT ?Keep a running count of eligible cumulative days (exclude days when a break of 7 days or greater in a work week) FORMTEXT ?that count toward employment outcome and benchmark achievement. FORMTEXT ? The previous recorded information for each benchmark should remain on the form. Eligible Premiums and Indication of Achievement at 90 Days FORMTEXT ? of Placement Section should be updated at Benchmark 6. Signatures must be gained at each benchmark 2- 6. FORMTEXT ? NOTE: VR Standards for Providers Chapter 18: Supported Employment Services provides more detailed requirements for payment. FORMTEXT ?Hour requirements as per the SESP-1 dated: FORMTEXT ?????Minimum hours to work per week: FORMTEXT ?????Maximum hours to work per week: FORMTEXT ?????Minimum hours to work per shift: FORMTEXT ?????Maximum hours to work per shift: FORMTEXT ?????Employer defined work week (for example: Sunday – Saturday): FORMTEXT ?????WeekDate 1st Day Work Week FORMTEXT ?????2nd Day Work Week FORMTEXT ?????3rd Day Work Week FORMTEXT ?????4th Day Work Week FORMTEXT ?????5th Day Work Week FORMTEXT ?????6th Day Work Week FORMTEXT ?????7th Day Work Week FORMTEXT ?????Total Hours Worked for WeekEligible Cumulative Day Count1. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????2. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????3. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????4. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????5. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????6. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????7. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????8. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????9. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????10. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????11. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????12. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????13. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????14. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????15. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????16. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????WeekDate 1st Day Work Week FORMTEXT ?????2nd Day Work Week FORMTEXT ?????3rd Day Work Week FORMTEXT ?????4th Day Work Week FORMTEXT ?????5th Day Work Week FORMTEXT ?????6th Day Work Week FORMTEXT ?????7th Day Work Week FORMTEXT ?????Total Hours Worked for WeekEligible Cumulative Day Count17. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????18. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????19. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????20. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????21. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????22. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????23. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????24. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????25. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????26. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????27. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????28. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????29. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????30. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????31. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????32. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????First day worked in first placement (month/day/year): FORMTEXT ????? and FORMCHECKBOX Still working or last day worked (month/day/year) FORMTEXT ?????.First day worked in second placement: FORMCHECKBOX Not applicable or Start date: FORMTEXT ????? FORMCHECKBOX Still working or End date: FORMTEXT ?????.First day worked in third placement: FORMCHECKBOX Not applicable or Start date: FORMTEXT ????? FORMCHECKBOX Still working or End date: FORMTEXT ?????.First day worked in forth placement: FORMCHECKBOX Not applicable or Start date: FORMTEXT ????? FORMCHECKBOX Still working or End date: FORMTEXT ?????.First day worked in fifth placement: FORMCHECKBOX Not applicable or Start date: FORMTEXT ????? FORMCHECKBOX Still working or End date: FORMTEXT ?????.Signatures FORMTEXT ?By signing below, I, the customer or the legally authorized representative (when applicable) understand and agree with the dates and hours FORMTEXT ?worked as indicated above, to be true and correct. FORMTEXT ?Customer’s signature FORMTEXT ?XDate: FORMTEXT ?????Customer’s legally authorized representative’s signature, if any: FORMTEXT ?XDate: FORMTEXT ?????Supported Employment Specialist’s Signature FORMTEXT ?By signing below, I, the Supported Employment Specialist, certify that: FORMTEXT ? I documented the information on the form for the customer represented on this form; FORMTEXT ?The customer’s and/or customer’s legally authorized representative’s signature on this form was obtained on the date stated in the date field of the form; FORMTEXT ? I handwrote my signature and the date below; and FORMTEXT ?I maintain the staff qualifications, including the UNT WISE credential, required for a Supported Employment Specialist, FORMTEXT ? as described in Standards for Providers and/or Service Authorization. FORMTEXT ?Supported Employment Specialist typed name: FORMTEXT ?????Supported Employment Specialist signature:X FORMTEXT ?Date: FORMTEXT ????? ................
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