State of Missouri



[pic] |State of Missouri - Rehabilitation Services for the Blind

Individualized Plan for Employment (IPE) | |

|Name |      |Case # |      |

|Type of IPE |Original Amendment Post Employment |

| |Supported Employment Extended Evaluation |

|Specific employment outcome selected by the individual consistent with their abilities, capabilities, strengths, interests, priorities, concerns, and resources: |

|      |

|Expected Employment (plan completion) Date:       |

|Services Needed To |Nature Of Service and Provider |Funding Source |To Begin |Review Method |

|Reach My Work Goal | | | | |

| 1 Assessment |      |      |      |      |

| 2 Counseling and Guidance |      |      |      |      |

| 3 Physical/Mental Restoration |      |      |      |      |

| 4 Vocational Training (OJT, Coaching) |      |      |      |      |

| 5 College/University Training |      |      |      |      |

| 6 ADL Blindness Skills Training |      |      |      |      |

| 7 Orientation/Mobility Training |      |      |      |      |

| 8 Rehabilitation Engineering Services |      |      |      |      |

| 9 Assistive Technology Aids/Devices |      |      |      |      |

| 10 Job Search |      |      |      |      |

| 11 Job Placement |      |      |      |      |

| 12 Maintenance |      |      |      |      |

| 13 Transportation |      |      |      |      |

| 14 Reader |      |      |      |      |

| 15 Interpreter |      |      |      |      |

| 16 Services to Family Members |      |      |      |      |

| 17 Occupational Tools/License |      |      |      |      |

| 18 Personal Care Attendant |      |      |      |      |

| 19 Extended Service Provider |      |      |      |      |

| 20 Other (Specify) |      |      |      |      |

|      | | | | |

|Client Responsibilities: (check those that apply) |

|I. General |

| Apply for (list items such as specific comparable benefits and provide the documentation) |

| |

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| Regularly review progress with counselor |

| Inform counselor of any changes |

| Provide financial information as appropriate |

|II. Training |

| Enroll/Register (and provide the documentation) |

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|Provide counselor with grade reports |

|Apply for Pell Grant (annually and provide the documentation) |

|III. Placement |

| Look for work |

|Inform counselor when job is found |

|IV. Other Client Responsibilities |

| Other (Specify)       |

|Post Employment |

|As assessed, Post Employment services ARE ARE NOT indicated at this time |

|I have been informed about and involved in choosing my goals, services, providers and methods used to procure services. |

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|Client Signature |

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|Date |

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|Qualified Vocational |

|Counselor Signature |

| |

|Date |

| |

|Required IPE review must be completed no later than: |      |

|Missouri Rehabilitation Services for the Blind provides Vocational Rehabilitation (VR) services to individuals with disabilities which allow them to prepare for, |

|enter into, engage in, or return to employment consistent with the individual's strengths, resources, priorities, concerns, abilities, capabilities and informed |

|choice. |

|ELIGIBILITY for Vocational Rehabilitation services is based only on the following requirements: The individual has a physical or mental disability which constitutes |

|or results in a substantial impediment to employment and the individual can benefit from the provision of Vocational Rehabilitation services. All applicants must |

|meet visual eligibility requirements established by Rehabilitation Services for the Blind. |

|CLIENT RIGHTS include the right to have your IPE reviewed at least annually. You have the right to fully participate in all amendments to your IPE. You have the |

|right to appeal any agency decision regarding your eligibility or ineligibility for services or any decision made by the agency on your behalf. You have the right |

|to receive all services and the entity or entities that will provide the services needed to achieve the employment outcome in the most integrated setting possible, |

|consistent with your individual needs and informed choice. You also have the right to receive notice of Privacy Practices Regarding your Protected Health |

|Information consistent with HIPAA. |

|CLIENT RESPONSIBILITIES include the responsibility to participate in the development and make efforts in carrying out your IPE and to comply with all the terms and |

|conditions as agreed to in your IPE this includes, but not limited to, give progress reports, returning phone calls, keeping appointments, and participating in |

|scheduled activities. If my name, address or telephone number changes, I will let my counselor know. I will also let my counselor know when I get a job, or have |

|obtained my rehabilitation goal. Finally, I will apply for comparable benefits and let my counselor know if I am getting or I am about to get such benefits (medical |

|services, grants, equipment, tuition, etc.) I understand that if I fail to comply with these responsibilities, I may be determined to be ineligible for further |

|services. |

|APPEAL PROCEDURES are assured for any applicant or eligible individual who is dissatisfied with any determination made by agency representatives. An applicant or |

|eligible individual may request an Administrative Review. You are, however, entitled to your option of Mediation or to a Fair Hearing by an impartial hearing officer|

|in lieu of an Administrative Review. A written request to the Deputy Director, FSD/Rehabilitation Services for the Blind, PO Box 2320, Jefferson City, Missouri |

|65102-2320 is required for the Review, Mediation or Fair Hearing. |

|CLIENT ASSISTANCE PROGRAM (CAP) services are available to Vocational Rehabilitation clients of Rehabilitation Services for the Blind. This resource is to help you |

|with any problems you may have with services provided by the agency. You may contact Missouri Protection and Advocacy Services at 925 South Country Club Drive, B-1, |

|Jefferson City, MO 65109. |

|OPTIONS FOR COMPLETION OF THE IPE: |

|The individual may develop the IPE: on his/her own; with the assistance of a qualified VR counselor; or with the assistance of anyone else who is willing to help. |

|Once an individual is determined eligible to receive VR services, he or she must develop an IPE. The individual must be given the opportunity to make an informed |

|choice in selecting, among other things, an employment outcome, needed VR services, and providers of those VR services. |

|The VR agency must provide the individual with information in writing, as well as in an appropriate mode of communication, explaining the assistance available to the|

|individual when developing the IPE as well as the full range of components that must be included in the IPE. |

|You may contact your counselor, local district office, use RSB's 800 number (800-592-6004) or the RSB website at www:dss.fsd/rsb. |

|Both the individual and the VR counselor must sign the IPE. |

|Employment outcomes are based on the federal standards for the determination of successful. Specific details for the client plan are in the Record of Service. |

|PERIODIC OR ANNUAL REVIEW(S) WAS/WERE CONDUCTED ON       |

|      |

|ADDITIONAL COMMENTS       |

|      |

|RSB TOLL-FREE NUMBER: 800-592-6004 |CAP TOLL-FREE NUMBER: 800-392-8667 |

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