VR3455 Provider Staff Information Form



Texas Workforce CommissionVocational Rehabilitation ServicesProvider Staff Information Form FORMTEXT ?Instructions: FORMTEXT ?Each entity must have an accurate and current VR3455, Provider Staff Information Form, on file for all personnel (including contracted FORMTEXT ? personnel) that provide TWC Vocational Rehabilitation services directly to customers, supervisors and program managers and FORMTEXT ? the director appointed by the legal authorized representative. FORMTEXT ?For response to an Electronic State Business Daily (EBSD) posting, follow the instructions in the ESBD posting, FORMTEXT ? otherwise submit updated forms to the Quality Assurance Specialist for VR (Q) or Regional Program Support Specialist (RPSS) and Contract Manager. FORMTEXT ? FORMTEXT ?Follow instructions on the form and in the TWC VR Standards for Providers. FORMTEXT ?The director on record with TWC and appointed by the entity’s legally authorized representative signs this form verifying the staff FORMTEXT ?member's qualifications as documented in the VR Standards for Providers (VR-SFP) manual. FORMTEXT ?Submit the form within 30 days FORMTEXT ? of any of the following: after hiring staff, significant change in a staff member’s job duties, FORMTEXT ? change in staff qualifications or a staff member is terminated. FORMTEXT ?Type all information on form using a computer and get all required signatures. FORMTEXT ?Complete all sections of the form. Record “N/A” (not applicable) if a question does not apply. FORMTEXT ? Keep a copy of the completed the VR3455, attachments, and supporting documentation for your records. FORMTEXT ?Reason for Submission FORMTEXT ? Date of submission: FORMTEXT ????? FORMCHECKBOX Application package Solicitation ID: FORMTEXT ????? FORMCHECKBOX New hire FORMCHECKBOX Termination of staff person FORMCHECKBOX Update of information due to change in information on file. For example, qualifications change.Contract #: FORMTEXT ????? FORMCHECKBOX Other: Specify: FORMTEXT ?????Entity’s Information FORMTEXT ? Entity: The business that is requesting or has been granted the bilateral contract with TWC to provide services on behalf of VR customers. FORMTEXT ?Entity’s legal name: FORMTEXT ????? Entity’s “doing business as” (DBA) name: FORMTEXT ?????Provide at least one of the following: FORMTEXT ?Employer Identification Number (EIN) (9 digits, issued by IRS): FORMTEXT ?????Last four digits of the sole proprietor’s Social Security Number: FORMTEXT ?????Staff Person’s Information FORMTEXT ? For the purpose of this form, “staff person” refers to persons classified as employees or independent contractors working for FORMTEXT ? the entity that has the TWC bilateral contract. FORMTEXT ?Staff person’s first name: FORMTEXT ?????Staff person’s last name: FORMTEXT ?????Other names used: FORMTEXT ?????Are you an independent contractor by the IRS definition and does the entity issue an IRS 1099-MISC, Miscellaneous Income?(An independent contractor performs services that can be controlled by the employer. For more information, see IRS Independent Contractor Defined.) FORMTEXT ? FORMTEXT ? FORMCHECKBOX Yes FORMCHECKBOX NoExperience and Skills FORMTEXT ? FORMCHECKBOX N/A. The staff person does not have any experience or skills in areas listed.Select all areas in which the staff has experience and skills. FORMTEXT ? FORMCHECKBOX Alcohol- or drug-abuse issues FORMCHECKBOX Intellectual and/or developmental disabilities FORMCHECKBOX Attention deficit hyperactivity disorder (ADHD) FORMCHECKBOX Learning disabilities FORMCHECKBOX Anxiety disorder FORMCHECKBOX Limited English proficiency (LEP) FORMCHECKBOX Autism spectrum disorders FORMCHECKBOX Mobility Impaired FORMCHECKBOX Back injury or musculoskeletal impairments FORMCHECKBOX Personality disorders FORMCHECKBOX Blindness FORMCHECKBOX Schizophrenia and other psychotic disorders FORMCHECKBOX Criminal histories FORMCHECKBOX Spinal cord injuries FORMCHECKBOX Deaf Blindness FORMCHECKBOX Students ages 14-22 FORMCHECKBOX Deafness FORMCHECKBOX Traumatic brain injuries FORMCHECKBOX Depression and other mood disorders FORMCHECKBOX Veterans FORMCHECKBOX Diabetes FORMCHECKBOX Visual impairments FORMCHECKBOX Epilepsy FORMCHECKBOX Other: FORMTEXT ????? FORMCHECKBOX Hearing impairments FORMCHECKBOX Other: FORMTEXT ????? FORMCHECKBOX HIV or AIDS FORMCHECKBOX Other: FORMTEXT ?????Describe the staff person’s experience and skills for any areas identified above. FORMTEXT ? The description should explain the staff person’s experience and skills in the identified areas. FORMTEXT ?????Language Skills FORMTEXT ? Select all languages in which the staff person is fluent. FORMTEXT ? FORMCHECKBOX American Sign Language (ASL) FORMCHECKBOX Spanish FORMCHECKBOX Arabic FORMCHECKBOX Tagalog FORMCHECKBOX Chinese FORMCHECKBOX Urdu FORMCHECKBOX English FORMCHECKBOX Vietnamese FORMCHECKBOX Hindi FORMCHECKBOX Other: FORMTEXT ????? FORMCHECKBOX Japanese FORMCHECKBOX Other: FORMTEXT ????? FORMCHECKBOX Korean FORMCHECKBOX Other: FORMTEXT ????? FORMCHECKBOX Persian FORMCHECKBOX Other: FORMTEXT ?????Does the staff person read braille? FORMCHECKBOX Yes FORMCHECKBOX NoSecondary Education FORMTEXT ? Select one: FORMTEXT ? FORMCHECKBOX High school diploma FORMCHECKBOX General Educational Development (GED) certificationTrade School and/or Training Program FORMTEXT ? Record all non-degree programs completed. FORMTEXT ? Copies of transcripts or certificates of completion must be submitted with this form. FORMTEXT ? FORMCHECKBOX N/A. Staff person did not attend a trade school or training program.Trade School or Training ProgramProgram or Course TitleVerified by SME, QASVR or RPSS FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX YesInitials: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX YesInitials: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX YesInitials: FORMTEXT ?????College or University History FORMTEXT ? Record earned associate’s, bachelor’s, master’s or doctoral degrees. Copies of diploma or transcriptions must be submitted with this form. FORMTEXT ? FORMCHECKBOX N/A. Staff person does not have a college or university education history. Name of College or UniversityDegree ReceivedMajor (and Minor, if applicable)Verified by SME, QASVR or RPSS FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX YesInitials: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX YesInitials: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX YesInitials: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX YesInitials: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX YesInitials: FORMTEXT ?????Record all incomplete associate’s, bachelor’s, master’s or doctoral degrees.Copies of transcriptions must be submitted with this form. FORMTEXT ? Name of College or UniversityIncomplete Degree Total Number of Hours Completed Verified by SME, QASVR or RPSS FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX YesInitials: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX YesInitials: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX YesInitials: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX YesInitials: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX YesInitials: FORMTEXT ?????Credentials, Certifications, and Licenses FORMTEXT ?Record all of the following: UNTWISE Credentials, FORMTEXT ?Center for Social Capital Certified Business Technical Assistance Consultant (CBTAC) certification, FORMTEXT ? and other credentials, certifications, or licenses such as Licensed Baccalaureate Social Worker (LBSW), FORMTEXT ? Licensed Master Social Worker (LMSW), and Licensed Clinical Social Worker (LCSW). FORMTEXT ?Copies of credentials, certifications, and licenses must be submitted with this form. FORMTEXT ? FORMCHECKBOX N/A. The staff person has no credentials, certifications, or licenses. FORMCHECKBOX The staff person is the director appointed by the legally authorized representative of the entity.Credential, Certification, or License TitleCredential, Certification, or License NumberExpiration DateVerified by SME, QASVR or RPSS FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX YesInitials: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX YesInitials: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX YesInitials: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX YesInitials: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX YesInitials: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX YesInitials: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX YesInitials: FORMTEXT ?????Endorsements FORMTEXT ?Record all UNTWISE Endorsement or Sign Language Proficiency Interview (SLPI) certifications. FORMTEXT ? Copies of endorsements and/or certifications must be submitted with this form. FORMTEXT ? FORMCHECKBOX N/A. The staff person has no endorsements.Title of EndorsementsEndorsement NumberExpiration DateVerified by SME, QASVR or RPSS FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX YesInitials: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX YesInitials: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX YesInitials: FORMTEXT ?????Employment Experience FORMTEXT ? FORMCHECKBOX N/A. Staff Person does not have employment experience applicable to service(s) provision.Résumés will not be accepted in place of this section. FORMTEXT ?Employer: FORMTEXT ?????Employed dates:from FORMTEXT ????? to FORMTEXT ?????Nature of duties: FORMTEXT ?????Employer: FORMTEXT ?????Employed dates:from FORMTEXT ????? to FORMTEXT ?????Nature of duties: FORMTEXT ?????Employer: FORMTEXT ?????Employed dates:from FORMTEXT ????? to FORMTEXT ?????Nature of duties: FORMTEXT ?????Services to be Provided by the Staff Person FORMTEXT ? Select a service only if you meet the minimum qualifications as described in the TWC VR Standards for Providers. FORMTEXT ? Selecting services you are not qualified to provide could result in adverse actions against the entity. FORMTEXT ? FORMCHECKBOX N/A. The staff person is not providing direct service for VR customers.Select all that apply. FORMTEXT ? Agency Use Only: Qualification was verified by SME, QASVR or RPSS FORMTEXT ? FORMCHECKBOX Assistive Technology Evaluation FORMCHECKBOX YesInitials: FORMTEXT ?????Comments, if any: FORMTEXT ????? FORMCHECKBOX Assistive Technology Training FORMCHECKBOX YesInitials: FORMTEXT ?????Comments, if any: FORMTEXT ????? FORMCHECKBOX Diabetes Self-Management Education FORMCHECKBOX YesInitials: FORMTEXT ?????Comments, if any: FORMTEXT ????? FORMCHECKBOX Environmental Work Assessment (EWA) FORMCHECKBOX YesInitials: FORMTEXT ?????Comments, if any: FORMTEXT ????? FORMCHECKBOX Independent Living Services for Older Individuals who are Blind FORMCHECKBOX YesInitials: FORMTEXT ?????Comments, if any: FORMTEXT ????? FORMCHECKBOX Job Placement (Bundled and Non-bundled) FORMCHECKBOX YesInitials: FORMTEXT ?????Comments, if any: FORMTEXT ????? FORMCHECKBOX Job Skills Training (JST) FORMCHECKBOX YesInitials: FORMTEXT ?????Comments, if any: FORMTEXT ????? FORMCHECKBOX Orientation and Mobility Training (O & M) FORMCHECKBOX YesInitials: FORMTEXT ?????Comments, if any: FORMTEXT ????? FORMCHECKBOX Personal Social Adjustment Training (PSAT) FORMCHECKBOX YesInitials: FORMTEXT ?????Comments, if any: FORMTEXT ????? FORMCHECKBOX Pre-Employment Transition Services (Pre-ETS) FORMCHECKBOX YesInitials: FORMTEXT ?????Comments, if any: FORMTEXT ????? FORMCHECKBOX Project SEARCH Asset Discovery Service FORMCHECKBOX YesInitials: FORMTEXT ?????Comments, if any: FORMTEXT ????? FORMCHECKBOX Project SEARCH Skills Training Service FORMCHECKBOX YesInitials: FORMTEXT ?????Comments, if any: FORMTEXT ????? FORMCHECKBOX Project SEARCH Job Placement Service FORMCHECKBOX YesInitials: FORMTEXT ?????Comments, if any: FORMTEXT ????? FORMCHECKBOX Self-Employment FORMCHECKBOX YesInitials: FORMTEXT ?????Comments, if any: FORMTEXT ????? FORMCHECKBOX Supportive Residential Services for Persons in Recovery FORMCHECKBOX YesInitials: FORMTEXT ?????Comments, if any: FORMTEXT ????? FORMCHECKBOX Supported Employment (SE) FORMCHECKBOX YesInitials: FORMTEXT ?????Comments, if any: FORMTEXT ????? FORMCHECKBOX Supported Self-Employment FORMCHECKBOX YesInitials: FORMTEXT ?????Comments, if any: FORMTEXT ????? FORMCHECKBOX Vocational Adjustment Training (VAT) FORMCHECKBOX YesInitials: FORMTEXT ?????Comments, if any: FORMTEXT ????? FORMCHECKBOX Vocational Evaluation/Vocational Assessment (including Situational Assessments) FORMCHECKBOX YesInitials: FORMTEXT ?????Comments, if any: FORMTEXT ????? FORMCHECKBOX Wellness Recovery Action Plans (WRAP) FORMCHECKBOX YesInitials: FORMTEXT ?????Comments, if any: FORMTEXT ????? FORMCHECKBOX Work Adjustment Training (WAT) FORMCHECKBOX YesInitials: FORMTEXT ?????Comments, if any: FORMTEXT ????? FORMCHECKBOX Work Experience Placement (WEP) FORMCHECKBOX YesInitials: FORMTEXT ?????Comments, if any: FORMTEXT ????? FORMCHECKBOX Work Experience Training (WET) FORMCHECKBOX YesInitials: FORMTEXT ?????Comments, if any: FORMTEXT ????? FORMCHECKBOX Other: FORMTEXT ????? FORMCHECKBOX YesInitials: FORMTEXT ?????Comments, if any: FORMTEXT ????? FORMCHECKBOX Other: FORMTEXT ????? FORMCHECKBOX YesInitials: FORMTEXT ?????Comments, if any: FORMTEXT ????? FORMCHECKBOX Other: FORMTEXT ????? FORMCHECKBOX YesInitials: FORMTEXT ?????Comments, if any: FORMTEXT ?????Agency Use OnlyComments: FORMTEXT ?????Verification Statements FORMTEXT ?Staff Person FORMTEXT ?I, the person named on this staff information form, certify that I have: FORMTEXT ?completed the form and acknowledge that a new complete VR3455, Provider Staff Information Form, must be submitted to TWC whenever FORMTEXT ? the information on this form changes; FORMTEXT ?reviewed the TWC VR Standards for Providers and confirm that I meet the qualifications for all services checked in FORMTEXT ? the “Services Provided by the Staff Person” section of this form; FORMTEXT ?attached proof of all diplomas, transcripts, credentials, certifications, specialty endorsements, and FORMTEXT ? licenses listed on this form; and FORMTEXT ?read and understood, and will abide by, the current TWC VR Standards for Providers and by all updates and changes made to it. FORMTEXT ?I acknowledge that failure to abide by the entity’s TWC contract requirements and TWC VR Standards for Providers might cause FORMTEXT ? adverse consequences for the entity, such as denial of payments, recoupment of payments, suspension FORMTEXT ? of service provisions to VR customers, or loss of an awarded contract. FORMTEXT ?Typed name of staff member: FORMTEXT ?????Handwritten signature of staff member: X FORMTEXT ?Date: FORMTEXT ?????Director’s Signature (When the legal representative is also the Director, signature is still required) FORMTEXT ?I, the director appointed by the entity’s legally authorized representative do have the authority to supervise this staff person, FORMTEXT ? certify that:all information recorded by the staff person named on this form has been verified; FORMTEXT ?I have reviewed the TWC VR Standards for Providers and the contract requirements, and I agree that the staff person meets the qualifications FORMTEXT ? for all services checked; FORMTEXT ? a copy of this form and supporting documentation is in the personnel file of the staff person and FORMTEXT ? will be made available to TWC upon request; FORMTEXT ?I acknowledge that a new complete VR3455 must be submitted to TWC whenever the information on this form changes; and FORMTEXT ? I acknowledge that failure to abide with the entity’s TWC contract requirements and TWC VR Standards for Providers might cause FORMTEXT ? adverse consequences for the entity, such as denial of payments, recoupment of payments, suspension of service provision to VR customers, or FORMTEXT ? loss of an awarded contract. FORMTEXT ? Typed name: FORMTEXT ?????Title: FORMTEXT ?????UNTWISE Credential Number: FORMTEXT ?????Date the UNTWISE Director Credential expires: FORMTEXT ?????Handwritten signature of Director: X FORMTEXT ?Date: FORMTEXT ?????Agency Use Only FORMTEXT ? Comments: FORMTEXT ?????Reviewers of the application: FORMTEXT ? DatePrinted NameTitleInitials FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? ................
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