VR1845B Bundled Job Placement Services Plan Part B and ...



Texas Workforce CommissionVocational Rehabilitation ServicesBundled Job Placement Services PlanPart B and Status Report FORMTEXT ?General Instructions FORMTEXT ?Instructions: Follow the instructions below when completing this form and its associated VR Standards: FORMTEXT ?VR1845A, Bundled Job Placement Services Placement Plan-Part A must be completed prior to the development of the following Placement Plan sections: FORMTEXT ? Employment Conditions and Employment Goal. FORMTEXT ?Before any services are provided, the Placement Plan-Part B will be completed electronically (on the computer) by VRS staff at the FORMTEXT ?Planning Meeting with all signatures obtained at the end of the meeting. FORMTEXT ?VRS staff member will place the original signed paper copy in the VRS case file. FORMTEXT ?At the conclusion of the meeting, VRS staff will provide to the provider: a printed paper copy of the signed Placement Plan-Part B and a FORMTEXT ? Microsoft Office Word file of the form so that the form can be used by the provider for each benchmark reporting period. The form will contain previously recorded information for each benchmark submitted. Each time the form is completed new signatures must be obtained prior to submitting to VRS. FORMTEXT ? FORMTEXT ? FORMTEXT ?If the employment goal changes or non-negotiable conditions become negotiable, a new updated Placement Plan must be completed by holding FORMTEXT ? a Job Placement Planning Meeting before the customer begins employment. The placement count does not start until the day after the Plan has been updated. FORMTEXT ? VRS staff members and the customer will make the final decisions FORMTEXT ? related to the employment goal and non-negotiable conditions. FORMTEXT ? Demographic Information FORMTEXT ? FORMCHECKBOX Basic Bundled Job Placement Services FORMCHECKBOX Enhanced Bundled Job Placement ServicesCustomer name: FORMTEXT ?????VRS case ID: FORMTEXT ?????Service authorization (SA) number: FORMTEXT ?????Placement Plan-Employment Conditions FORMTEXT ?Instructions: FORMTEXT ?VRS staff will record all Employment Conditions in measurable terms and indicate if the Employment Conditions are “negotiable” or FORMTEXT ? “non-negotiable.” FORMTEXT ? Address support needs and any mandatory commitments that must be planned around for the customer to maintain a long-term Job Placement. FORMTEXT ?Record “N/A” if an Employment Condition criterion does not apply to the customer. FORMTEXT ?Job placement specialist will check the box under the appropriate benchmark to indicate whether the Employment Condition was achieved. FORMTEXT ? If the Employment Condition was not achieved, the box will not be checked. FORMTEXT ? For the cumulative day count for 45 and 90 days, the customer must have achieved the nonnegotiable conditions (i.e., hours per week and hours per shift). FORMTEXT ? FORMTEXT ?For the 5th day, the customer must have worked 5 days on the job, not cumulative calendar days. For the 45th and 90th day counts, begin the count using the first day/shift worked. FORMTEXT ? FORMTEXT ?Employment Conditions FORMTEXT ?NegotiableNon-negotiableAchieved at:5th day45th day90th day1. Minimum and maximum number of hours to work per week: FORMTEXT ?Minimum FORMTEXT ????? and maximum FORMTEXT ?????N/A FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 2. Minimum and maximum hours per shift: FORMTEXT ?Minimum FORMTEXT ????? and maximum FORMTEXT ?????N/A FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 3. Weekday hours available (Record the times the customer is available to work each day.): FORMTEXT ?Monday: FORMTEXT ?????Tuesday: FORMTEXT ?????Wednesday: FORMTEXT ?????Thursday: FORMTEXT ?????Friday: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 4. Weekend hours available (Record the times the customer is available to work each day.): FORMTEXT ?Saturday: FORMTEXT ?????Sunday: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 5. Earnings cannot be less than (choose one): FORMTEXT ? FORMTEXT ?????/month, or FORMTEXT ?????/week, or FORMTEXT ?????/hour FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 6. Distance or time willing to travel to and from work: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 7. Transportation method(s): FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 8. Mandatory commitment(s) that must be accommodated:(for example, child and/or elder care, religious observances, entitlements, waivers, criminal charges or convictions, and parole): FORMTEXT ? FORMTEXT ? FORMTEXT ?????N/A FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????N/A FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????N/A FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 9. List job site accommodation(s) and other support needs.(for example, physical restrictions, supervision, training needs, or adaptive equipment): FORMTEXT ? FORMTEXT ? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 10. Other: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 11. Other: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Placement Plan - Employment Goal(s) FORMTEXT ?Instructions: FORMTEXT ?VRS staff will record no more than 3 Standard Occupational Classification (SOC) System Codes using the full, 6-digit SOC Cluster-SOC-Codes. FORMTEXT ? VRS Staff will record the SOC Occupational Title or a description of the job responsibilities, skills, or work duties. FORMTEXT ?The job tasks for the job obtained must meet the SOC code’s job tasks. SOC job task can be found at: FORMTEXT ?Job Placement Specialist records the achievement of the Employment Goal at each Benchmark timeframe. FORMTEXT ? One goal must be achieved. FORMTEXT ?6-Digit SOC Code(s)SOC Occupational Title or Descripition: FORMTEXT ?Achieved at:5th day45th day90th day FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Does the customer’s employment goal support the need for a résumé? FORMCHECKBOX Yes FORMCHECKBOX NoMock interviews must be video-recorded? FORMCHECKBOX Yes FORMCHECKBOX NoService Delivery FORMTEXT ? VR counselor approves the training required in Benchmark A to be provided: (check one) FORMCHECKBOX In person FORMCHECKBOX Remotely FORMCHECKBOX Combination, in person and remotely.VR counselor approves the two required visits between 5th day of employment and 45 day be provided: FORMTEXT ? FORMCHECKBOX In person at job site FORMCHECKBOX In person at or away from job site FORMCHECKBOX Remotely FORMCHECKBOX Combination, in person and remotely.VR counselor approves the two required between the 46th day of employment and the 90th day employment be provided: FORMTEXT ? FORMCHECKBOX In person at job site FORMCHECKBOX In person at or away from job site FORMCHECKBOX Remotely FORMCHECKBOX Combination, in person and remotely.Note: VR counselor must consult with their supervisor prior to approving remote services for the required site visits. FORMTEXT ?Provider and VR Contacts FORMTEXT ?Job Placement Specialist maintains contact with VR Counselor every: FORMTEXT ?????Premiums FORMTEXT ? Instructions: FORMTEXT ? The VR Counselor will indicate the premiums to be purchased. FORMTEXT ?Service Authorization(s) for premium(s) must be issued with Benchmark A service authorization. FORMTEXT ?The Job Placement Specialist identifies compliance with the required qualifications for the premium and will invoice for the premium(s) after the completion of Benchmark C. FORMTEXT ? FORMTEXT ?Eligible Premium(s) FORMTEXT ?Achieved Premium(s) after completion of Benchmark CAutism Service Premium FORMTEXT ? FORMCHECKBOX Yes FORMCHECKBOX NoAutism Service Premium FORMTEXT ? FORMCHECKBOX Yes FORMCHECKBOX NoCriminal Background Premium FORMTEXT ? FORMCHECKBOX Yes FORMCHECKBOX NoCriminal Background Premium FORMTEXT ? FORMCHECKBOX Yes FORMCHECKBOX NoDeaf Service Premium FORMTEXT ? FORMCHECKBOX Yes FORMCHECKBOX NoDeaf Service Premium FORMTEXT ?If yes, attach proof of certification FORMCHECKBOX Yes FORMCHECKBOX NoProfessional Placement Premium FORMTEXT ? FORMCHECKBOX Yes FORMCHECKBOX NoProfessional Placement Premium FORMTEXT ?If yes, attach proof of degree FORMCHECKBOX Yes FORMCHECKBOX NoWage Premium FORMTEXT ? FORMCHECKBOX Yes FORMCHECKBOX NoWage Premium FORMTEXT ?If yes, attach detailed pay statement FORMCHECKBOX Yes FORMCHECKBOX NoOther: FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoOther: FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoJob Placement Information FORMTEXT ?Instructions: Record the start date and end dates, if applicable, for placements gained and lost. FORMTEXT ?First placement start date: FORMTEXT ????? Has customer required multiple placements? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, enter the applicable start and end dates below: FORMTEXT ?End date of first placement: FORMTEXT ????? Start date of second placement: FORMTEXT ?????End date of second placement: FORMTEXT ?????Start date of third placement: FORMTEXT ?????Employer Information FORMTEXT ?Instructions: Update at each benchmark when a change occurs and for each position held by the customer. FORMTEXT ?Completed for: FORMTEXT ? FORMCHECKBOX First Placement FORMCHECKBOX Second Placement FORMCHECKBOX Third PlacementCompany name: FORMTEXT ?????Street address (include suite number, if any): FORMTEXT ?????City: FORMTEXT ????? State: FORMTEXT ?????ZIP code: FORMTEXT ?????Main phone number: ( FORMTEXT ???) FORMTEXT ?????Company website: FORMTEXT ?????Supervisor’s (or contact person’s) name: FORMTEXT ?????Supervisor’s (or contact person’s) title: FORMTEXT ?????Supervisor’s direct phone number: ( FORMTEXT ???) FORMTEXT ?????Supervisor’s email address: FORMTEXT ?????Select the best method and time to contact the customer’s supervisor: FORMTEXT ? FORMCHECKBOX Phone FORMCHECKBOX Email FORMCHECKBOX In personDay and time: FORMTEXT ?????Customer Employment Information FORMTEXT ?Instructions: Update at each benchmark when a change occurs and for each position held by the customer. FORMTEXT ?Completed for: FORMCHECKBOX First Placement FORMCHECKBOX Second Placement FORMCHECKBOX Third PlacementCustomer’s job title: FORMTEXT ?????Description of job duties and responsibilities: FORMTEXT ?????How does the employer classify the position (check all that apply; seasonal employment is not appropriate, unless approved by the VR Director using the VR3472, Contracted Service Modification Request form): FORMTEXT ? FORMCHECKBOX Permanent FORMCHECKBOX Full-time FORMCHECKBOX Part-time FORMCHECKBOX Temp-to-hire when a prerequisite for continued employment after the probationary period ends FORMCHECKBOX As needed (PRN) when the minimum and maxium hours worked are maintained as identied on the VR1845B FORMCHECKBOX Other: Describe: FORMTEXT ?????Work Schedule: Record the start time, end time of work day and total hours worked daily below. FORMTEXT ?Employer defined work week (for example, Sunday – Saturday): FORMTEXT ?????Weekday:MondayTuesdayWednesdayThursdayFridaySaturdaySundayStart Time: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????End Time: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Total Hours: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Average hours customer works weekly: FORMTEXT ?????Do you expect the customer’s hours to change weekly? FORMTEXT ? FORMCHECKBOX Yes FORMCHECKBOX NoHourly wage: FORMTEXT ?????Gross weekly earnings: FORMTEXT ?????The customer is paid: FORMCHECKBOX Weekly FORMCHECKBOX Bi-Weekly (every two weeks) FORMCHECKBOX Monthly (one time each month) FORMCHECKBOX Bi-Monthly (twice each month) FORMCHECKBOX Other: FORMTEXT ????? Comments, if any: FORMTEXT ?????Service Delivery Information at Placement—5th day FORMTEXT ?Record the first 5 days the customer worked performing work duties and hours worked each day. FORMTEXT ?Day 1Date: FORMTEXT ?????Hours Worked: FORMTEXT ?????Comments: FORMTEXT ?????Day 2Date: FORMTEXT ?????Hours Worked: FORMTEXT ?????Comments: FORMTEXT ?????Day 3Date: FORMTEXT ?????Hours Worked: FORMTEXT ?????Comments: FORMTEXT ?????Day 4Date: FORMTEXT ?????Hours Worked: FORMTEXT ?????Comments: FORMTEXT ?????Day 5Date: FORMTEXT ?????Hours Worked: FORMTEXT ?????Comments: FORMTEXT ?????Employment schedule and work hours was verified through: FORMCHECKBOX Employer contact FORMCHECKBOX Customer contact FORMCHECKBOX Pay Stub FORMCHECKBOX Observing the customer at work FORMCHECKBOX Other. Describe: FORMTEXT ?????Describe the role(s) of the Job Placement Specialist in assisting the customer with obtaining and maintaining the job. FORMTEXT ? Include all phone calls, visits, contacts with the customer dating each entry and providing a brief summary of each visit. FORMTEXT ?????Describe any steps taken to customize the position for the customer to meet the needs of the customer and the business. (for example, blending job descriptions) FORMTEXT ? FORMTEXT ? FORMTEXT ?????Describe all accommodations, compensatory techniques, and special training needs identified or established to increase the customer’s performance in the work setting: (environmental changes, assistive technology devices, or work process) FORMTEXT ? FORMTEXT ?????Describe any consultations made with the business. FORMTEXT ?????Service Delivery Information at Placement, 45th day- Benchmark B FORMTEXT ?The customer has been employed and worked at least 45 days FORMTEXT ? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/AVisits with the Customer FORMTEXT ?Instructions: Record a brief summary of the visits between the 5th day and 45th day of the customer’s employment. Must have at least two visits using the method indicated above, to achieve the outcomes required for payment in the VR-SFP. FORMTEXT ? FORMTEXT ?Date: FORMTEXT ?????Summary of visit: FORMTEXT ?????Date: FORMTEXT ?????Summary of visit: FORMTEXT ?????Date: FORMTEXT ?????Summary of visit: FORMTEXT ?????Date: FORMTEXT ?????Summary of visit: FORMTEXT ?????Date: FORMTEXT ?????Summary of visit: FORMTEXT ?????Date: FORMTEXT ?????Summary of visit: FORMTEXT ?????Employment was verified through: FORMCHECKBOX Employer contact FORMCHECKBOX Observing the customer at work FORMCHECKBOX Customer contact FORMCHECKBOX Other: Describe: FORMTEXT ?????Describe all accommodations, compensatory techniques, and special training needs identified or established at the worksite: FORMTEXT ?????Describe how the customer has adjusted to the job. FORMTEXT ? Include all issues or concerns and how they were addressed by the provider, employer, and customer: FORMTEXT ?????Record a summary of the customer’s performance related to the job’s essential and nonessential responsibilities: FORMTEXT ?????Describe any consultations made with the business: FORMTEXT ?????Service Delivery Information at Placement, 90th day- Benchmark C FORMTEXT ? The customer has been employed and worked at least 90 days FORMTEXT ? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/AVisits with the Customer FORMTEXT ?Instructions: Record a brief summary of the visits between 46 day and 90th day of employment of the customer’s employment. Must have at least two visits using the method indicated above, to achieve the outcomes required for payment in the VR-SFP. FORMTEXT ? FORMTEXT ? Date: FORMTEXT ?????Summary of visit: FORMTEXT ?????Date: FORMTEXT ?????Summary of visit: FORMTEXT ?????Date: FORMTEXT ?????Summary of visit: FORMTEXT ?????Date: FORMTEXT ?????Summary of visit: FORMTEXT ?????Date: FORMTEXT ?????Summary of visit: FORMTEXT ?????Date: FORMTEXT ?????Summary of visit: FORMTEXT ?????Employment was verified through: FORMCHECKBOX Employer contact FORMCHECKBOX Observing the customer at work FORMCHECKBOX Customer contact FORMCHECKBOX Other: Describe: FORMTEXT ?????Describe all accommodations, compensatory techniques, and special training needs identified or established at the worksite: FORMTEXT ?????Describe how the customer has adjusted to the job. FORMTEXT ? Include all issues or concerns and how they were addressed by the provider, employer, and customer: FORMTEXT ?????Record a summary of the customer’s performance related to the job’s essential and nonessential responsibilities: FORMTEXT ?????Describe any consultations made with the business: FORMTEXT ?????Additional Comments FORMTEXT ?Additional comments, if any: FORMTEXT ?????Reason for Report Submission FORMTEXT ?Instructions: New original signatures must be added each time the form is submitted. Indicate below the reason the form is being submitted. FORMTEXT ?For: FORMCHECKBOX Original Planning Meeting FORMCHECKBOX Updated Planning Meeting: Date: FORMTEXT ????? FORMCHECKBOX Benchmark A Reporting Period FORMCHECKBOX Benchmark B Reporting Period FORMCHECKBOX Benchmark C Reporting Period FORMCHECKBOX Other, describe: FORMTEXT ?????VR Counselor Signature (only required at the Placement Planning Meeting(s)) FORMTEXT ?By signing below, I, the customer’s Vocational Rehabilitation Counselor agree with the Employment Conditions, Employment Goal and Premium service recorded on this Placement Plan Report- Part 2 during the Job Placement Planning Meeting. FORMTEXT ? FORMTEXT ?VR Counselor’s signature: FORMTEXT ?XDate: FORMTEXT ?Customer Signatures FORMTEXT ?Verification of the customer’s and/or customer’s authorized representative’s satisfaction and service delivery obtained by: FORMTEXT ? FORMCHECKBOX Handwritten signature FORMCHECKBOX Digital signature (See VR-SFP 3.11.1 Documentation and Signatures) FORMCHECKBOX By sending a copy of the document returned with a scanned signature FORMCHECKBOX Unable to obtain signature, describe attempts: FORMTEXT ?????By signing below, I, the customer or authorized representative, agree with the Employment Conditions and Employment Goal recorded on this Placement Plan Report - Part 2 during the Job Placement Planning Meeting and the information recorded within the report above. If you are not satisfied, do not sign. Contact your VR counselor. FORMTEXT ? FORMTEXT ? FORMTEXT ?Customer’s signature:X FORMTEXT ?Date Signed: FORMTEXT ?????Customer’s authorized representative’s signature, if anyX FORMTEXT ?Date Signed: FORMTEXT ?????Provider Signatures FORMTEXT ?Type of Provider: FORMCHECKBOX Traditional-bilateral contractor FORMCHECKBOX Transition Educator FORMCHECKBOX Non-traditional Premiums to be invoiced: FORMCHECKBOX None FORMCHECKBOX Autism FORMCHECKBOX Blind and Visually Impaired FORMCHECKBOX Brain Injury FORMCHECKBOX Deaf FORMCHECKBOX other, specify: FORMTEXT ?????Job Placement Specialist FORMTEXT ?By signing below, I certify that: FORMTEXT ? the above dates, times, and services are accurate; FORMTEXT ?I personally facilitated all training, meeting all outcomes required for payment and documented the service, as prescribed in the VR-SFP and service authorization; FORMTEXT ? FORMTEXT ?Verification of the customer’s and/or customer’s authorized representative’s satisfaction and service delivery obtained as stated above; FORMTEXT ?I maintain the staff qualifications required for a Job Placement Specialist as described in the VRSFP or Service Authorization; and FORMTEXT ?I signed my signature and entered the date below. FORMTEXT ?Typed or Printed name of Job Placement Specialist 1: FORMTEXT ?????Signature: (See VR-SFP 3.11.1 Documentation and Signatures)X FORMTEXT ?Date Signed: FORMTEXT ?????Select all that apply: FORMCHECKBOX UNTWISE Credentialed with ID: FORMTEXT ????? FORMCHECKBOX VR3490-Waiver Proof Attached FORMCHECKBOX Transition Educator FORMCHECKBOX Non-traditional FORMCHECKBOX RID/BEI/SLIPI with Number: FORMTEXT ????? or FORMCHECKBOX proof attachedTyped or Printed name name of Job Placement Specialist 2 (if any): FORMTEXT ?????Signature: (See VR-SFP 3.11.1 Documentation and Signatures)X FORMTEXT ?Date Signed: FORMTEXT ?????Select all that apply: FORMCHECKBOX UNTWISE Credentialed with ID: FORMTEXT ????? FORMCHECKBOX VR3490-Waiver Proof Attached FORMCHECKBOX Transition Educator FORMCHECKBOX Non-traditional FORMCHECKBOX RID/BEI/SLIPI with Number: FORMTEXT ????? or FORMCHECKBOX proof attachedDirector (only required for Traditional-Bilateral Contractors) FORMTEXT ?By signing below, I, the Director, certify that: FORMTEXT ? I ensure that the services were provided by qualified staff, met all outcomes required for payment, and services were documented, as prescribed in the VR-SFP and service authorization; FORMTEXT ? FORMTEXT ?I maintain UNTWISE Director credential, as prescribed in VR-SFP; FORMTEXT ? I signed my signature and entered the date below. FORMTEXT ?Director Typed or Printed name: FORMTEXT ?????Director Signature: (See VR-SFP 3.11.1 Documentation and Signatures)X FORMTEXT ?Date Signed: FORMTEXT ?????Select all that apply: FORMTEXT ? FORMCHECKBOX UNTWISE Credentialed with ID: FORMTEXT ????? FORMCHECKBOX VR3490-Waiver Proof AttachedVRS 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 ?When Job Placement Specialist is a Transition Educator or Non-Traditional provider, skip this section. 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 CredentialJob Placement Specialist’s Credential: FORMTEXT ?UNTWISE website or attached VR3490 verifies, for the dates of service, the Job Placement Specialist listed above: FORMTEXT ? FORMCHECKBOX maintained or waived the required UNTWISE Credential FORMCHECKBOX did not hold a valid UNTWISE CredentialUNTWISE Endorsements: FORMTEXT ?UNTWISE website verifies, for the dates of service, the Job Placement Specialist listed above maintained the following endorsement: FORMTEXT ? FORMCHECKBOX None FORMCHECKBOX Autism FORMCHECKBOX Blind and Visually Impaired FORMCHECKBOX Brain Injury FORMCHECKBOX other, specify: FORMTEXT ?????Qualifications Related to Deaf Premium: FORMTEXT ?Attached documentation verifies, for the dates of service, the Job Placement Specialist listed above maintained one of the following: FORMTEXT ? FORMCHECKBOX not applicable/no attachment FORMCHECKBOX BEI FORMCHECKBOX RID FORMCHECKBOX SLIPIVerification 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 NoVerifed the training was provided in the environment(s) (in person, remotely or combination) indicated on the referral form. FORMCHECKBOX Yes FORMCHECKBOX NoWhen applicable, verify a copy of an approved VR3472 is attached to the report? FORMCHECKBOX NA FORMCHECKBOX Yes FORMCHECKBOX NoVerified that the customer’s current employment and employer information is described on form FORMCHECKBOX Yes FORMCHECKBOX NoVerified the customer worked 5 days prior to achievement of Benchmark A or worked 45 FORMTEXT ? days for achievement of Benchmark B or worked 90 days for achievement of Benchmark C FORMTEXT ? FORMCHECKBOX Yes FORMCHECKBOX NoVerified there were 2 in person visits at or away from jobsite with the customer from day 6 through day 45 and from day 46 through 90 FORMTEXT ? FORMCHECKBOX Yes FORMCHECKBOX NoVerified the customer’s satisfaction with the training through signature on the form and/or by VR staff member contact with customer 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 the employment is in an integrated employment setting FORMCHECKBOX Yes FORMCHECKBOX NoVerified customer achieved 100% of non-negotiable employment conditions and at least 50% of the negotiable employment conditions at achievement of each benchmark FORMTEXT ? FORMCHECKBOX Yes FORMCHECKBOX NoVerified customer achieved one of the six-digit SOCs listed as a measurable employment goal FORMCHECKBOX Yes FORMCHECKBOX NoVerified the customer received necessary accommodations, supplies and resources; various instructional approaches were used; and the customer has the ability to use compensatory techniques to increase ability to perform task and skills FORMTEXT ? FORMCHECKBOX Yes FORMCHECKBOX NoVerified at the original or any additional job placements, Job Placement Specialist assisted the customer in securing the job placement (training, job leads, etc.) FORMTEXT ? FORMCHECKBOX Yes FORMCHECKBOX NoVerified the customer was trained and demonstrated knowledge of and ability to perform skills/tasks as required in the service description and outcomes required for payment FORMTEXT ? FORMCHECKBOX Yes FORMCHECKBOX NoVerified the products produced from the service are accurate, professional, and of acceptable quality (e.g. self-assessments, résumés, elevator speech, employment conditions, extension activities) 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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