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, 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). 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 ?????Solicitation ID: FORMTEXT ????? or Contract #: FORMTEXT ????? FORMCHECKBOX Application package FORMCHECKBOX New hire FORMCHECKBOX Termination of staff person FORMCHECKBOX Update of information (For example, qualifications change.) 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 ?????Experience and Skills FORMTEXT ?UNTWISE Endorsements held: FORMCHECKBOX N/A FORMCHECKBOX Autism FORMCHECKBOX Blind FORMCHECKBOX Brain Injury FORMCHECKBOX Other: FORMTEXT ?????Describe your experience and skills working with individuals with disabilities, including disability groups. FORMTEXT ?????Language Skills FORMTEXT ? Select all languages in which the staff person is fluent. FORMTEXT ? FORMCHECKBOX American Sign Language (ASL) FORMCHECKBOX Hindi FORMCHECKBOX Korean FORMCHECKBOX Tagalog FORMCHECKBOX Arabic FORMCHECKBOX Japanese FORMCHECKBOX Persian FORMCHECKBOX Urdu FORMCHECKBOX Chinese FORMCHECKBOX English FORMCHECKBOX Spanish FORMCHECKBOX Vietnamese 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) certificationCollege 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 ?????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 ?????Credentials, Certifications, and Licenses FORMTEXT ?Record all of the following: UNTWISE Credentials and Endorsements, FORMTEXT ?Center for Social Capital Certified Business Technical Assistance Consultant (CBTAC) certification, FORMTEXT ? Sign Language Proficiency Interview (SLPI) certifications, and FORMTEXT ?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, Endorsement, Certification, or License TitleCredential, Endorsement 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 ?????Employment Experience FORMTEXT ?Provide paid and unpaid work experience. FORMTEXT ? Résumés will not be accepted in place of this section. FORMTEXT ? FORMCHECKBOX N/A. Staff Person does not have employment experience applicable to service(s) provision.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 verified by SME, QASVR or RPSS FORMTEXT ?Blind Services FORMTEXT ? FORMCHECKBOX Assistive Technology Evaluation for Sight-Related Disabilities FORMCHECKBOX Yes FORMCHECKBOX NoInitials: FORMTEXT ????? FORMCHECKBOX Assistive Technology Training for Sight-Related Disabilities FORMCHECKBOX Yes FORMCHECKBOX NoInitials: FORMTEXT ????? FORMCHECKBOX Diabetes Self-Management Education FORMCHECKBOX Yes FORMCHECKBOX NoInitials: FORMTEXT ????? FORMCHECKBOX Independent Living Services for Older Individuals who are Blind FORMCHECKBOX Yes FORMCHECKBOX NoInitials: FORMTEXT ????? FORMCHECKBOX Orientation and Mobility Training (O & M) FORMCHECKBOX Yes FORMCHECKBOX NoInitials: FORMTEXT ?????Employment Services FORMTEXT ? FORMCHECKBOX Career Planning Assessment (CPA) FORMCHECKBOX Yes FORMCHECKBOX NoInitials: FORMTEXT ????? FORMCHECKBOX Environmental Work Assessment (EWA) FORMCHECKBOX Yes FORMCHECKBOX NoInitials: FORMTEXT ????? FORMCHECKBOX Job Placement (Bundled and Non-bundled) FORMCHECKBOX Yes FORMCHECKBOX NoInitials: FORMTEXT ????? FORMCHECKBOX Job Skills Training (JST) FORMCHECKBOX Yes FORMCHECKBOX NoInitials: FORMTEXT ????? FORMCHECKBOX Personal Social Adjustment Training (PSAT) FORMCHECKBOX Yes FORMCHECKBOX NoInitials: FORMTEXT ????? FORMCHECKBOX Self-Employment FORMCHECKBOX Yes FORMCHECKBOX NoInitials: FORMTEXT ????? FORMCHECKBOX Supported Self-Employment FORMCHECKBOX Yes FORMCHECKBOX NoInitials: FORMTEXT ????? FORMCHECKBOX Supported Employment (SE) FORMCHECKBOX Yes FORMCHECKBOX NoInitials: FORMTEXT ????? FORMCHECKBOX Vocational Adjustment Training (VAT) FORMCHECKBOX Yes FORMCHECKBOX NoInitials: FORMTEXT ????? FORMCHECKBOX Vocational Evaluation (VE) FORMCHECKBOX Yes FORMCHECKBOX NoInitials: FORMTEXT ????? FORMCHECKBOX Work Adjustment Training (WAT) FORMCHECKBOX Yes FORMCHECKBOX NoInitials: FORMTEXT ????? FORMCHECKBOX Work Experience Placement (WEP) FORMCHECKBOX Yes FORMCHECKBOX NoInitials: FORMTEXT ????? FORMCHECKBOX Work Experience Training (WET) FORMCHECKBOX Yes FORMCHECKBOX NoInitials: FORMTEXT ?????Pre-Employment Transition Services (Pre-ETS) FORMTEXT ? FORMCHECKBOX Pre-Employment Transition Services (Pre-ETS) FORMCHECKBOX Yes FORMCHECKBOX NoInitials: FORMTEXT ?????Project SEARCH Services FORMTEXT ? FORMCHECKBOX Project SEARCH Asset Discovery Service FORMCHECKBOX Yes FORMCHECKBOX NoInitials: FORMTEXT ????? FORMCHECKBOX Project SEARCH Skills Training Service FORMCHECKBOX Yes FORMCHECKBOX NoInitials: FORMTEXT ????? FORMCHECKBOX Project SEARCH Job Placement Service FORMCHECKBOX Yes FORMCHECKBOX NoInitials: FORMTEXT ?????Mental Health and Substance Use Services FORMTEXT ? FORMCHECKBOX Supportive Residential Services for Persons in Recovery FORMCHECKBOX Yes FORMCHECKBOX NoInitials: FORMTEXT ????? FORMCHECKBOX Wellness Recovery Action Plans (WRAP) FORMCHECKBOX Yes FORMCHECKBOX NoInitials: FORMTEXT ?????Use if Service not listed Above FORMTEXT ? FORMCHECKBOX Other: FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoInitials: FORMTEXT ????? FORMCHECKBOX Other: FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoInitials: FORMTEXT ?????Agency Use Only: Comments: FORMTEXT ?????Transportation of VR Customers FORMTEXT ?Do you plan to transport VR customers in a personal vehicle while providing services? FORMCHECKBOX Yes FORMCHECKBOX NoInsurance Information FORMTEXT ?Agency Use OnlyQ or RPSS VerifiedInsuranceName of Carrier: FORMTEXT ?????Expiration Date: FORMTEXT ?????Proof of Insurance attached? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX NoVerification 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; FORMTEXT ?read and understood, and will abide by, the current TWC VR Standards for Providers and by all updates and changes made to it; and FORMTEXT ?submitted proof of carrying of minimum liability requirements of the Texas Department of Insurance, if planning to transport the customer in personal vehicle. FORMTEXT ? 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 or digital 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 or digital signature of Director: X FORMTEXT ?Date: FORMTEXT ?????Agency Use Only FORMTEXT ? Comments: FORMTEXT ?????Reviewers of the application: FORMTEXT ? DateNameTitleInitials FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? ................
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