VR1641 Supported Employment Assessment Report (SEA)



Texas Workforce CommissionVocational Rehabilitation ServicesSupported Employment Assessment Report (SEA) FORMTEXT ?General Instructions FORMTEXT ?Instructions: Complete the entire form electronically FORMTEXT ?VR1641, Supported Employment Assessment (SEA), is a detailed document that describes the customer’s interests, preferences, and support FORMTEXT ? needs and provides insight into the interventions that may lead to a successful job match and retention. FORMTEXT ? For customers who have a complete Environmental Work Assessment (EWA) completed information collected in FORMTEXT ? the EWA is included in the Assessment Summary. FORMTEXT ?The following Discovery activities cannot be held remotely: FORMTEXT ? FORMTEXT ?customer's interviews to observe skills and identify interests;home visits;work skills observations; andinformational interviews.The following may be held remotely if provided following VR-SFP 3.6.4.1 Remote Service Delivery:meetings between the Supported Employment specialist and the customer's circle of supports; andSESP-1 meeting to develop the Supported Employment Service Plan. FORMTEXT ? FORMTEXT ? FORMTEXT ?. NOTE: VR Standards for Providers Chapter 18: Supported Employment Services provides more detailed requirements for payment. FORMTEXT ?Service Information FORMTEXT ?Service authorization (SA) numbers: FORMTEXT ?????SEA process: Discovery dates must be within the SA start and end dates. FORMTEXT ? Date SEA was initiatedEnter date of first meeting with the customer: FORMTEXT ?????Date SEA was finishedEnter date of last meeting with the customer: FORMTEXT ?????Customer Identification Information FORMTEXT ?Last name: FORMTEXT ?????First name: FORMTEXT ?????Middle name: FORMTEXT ?????VRS case ID: FORMTEXT ?????Does the customer have a legal representative? FORMCHECKBOX Yes FORMCHECKBOX No If yes, enter name of the person: FORMTEXT ?????Alternate Contact Person’s Information FORMTEXT ?Alternate contact person’s name: FORMTEXT ?????Alternate contact person’s email address: FORMTEXT ?????Alternate’s primary phone number: ( FORMTEXT ???) FORMTEXT ?????Alternate’s secondary phone number: ( FORMTEXT ???) FORMTEXT ????? Customer SEA Interview Summary FORMTEXT ?Customer Discovery Interview FORMTEXT ?The Customer SEA Interview should be completed first and should be conducted only with the customer. FORMTEXT ? The goal is to stimulate participation that will help you learn about the customer’s interests from the customer’s perspective FORMTEXT ? rather than from the perspective of a caregiver or a professional social services employee. FORMTEXT ? If the customer cannot give answers to the questions in this section, the provider will need to gain the information through FORMTEXT ? observations of the customer participating in SEA activities. FORMTEXT ? Provide a summary of the Customer interview. Include factors related to interests, abilities, capabilities, strengths, skills, talents, FORMTEXT ? challenges, and concerns. The summary should address availability for work, motivations, and FORMTEXT ? barriers to engage in employment. FORMTEXT ?????Circle of Support Members FORMTEXT ?The interviews with Circle of Support members must be completed to verify the information provided by the customer and to gather FORMTEXT ? additional detail needed to begin identifying options for employment. The Circle of Support includes FORMTEXT ? family (parent or guardian, spouse, children, siblings), friends, and other people in the FORMTEXT ? community that are available to support the customer with employment. FORMTEXT ?Record Circle of Support information below: FORMTEXT ?Name: FORMTEXT ?????Relationship: FORMTEXT ?????Support that can be provided: FORMTEXT ?????Name: FORMTEXT ?????Relationship: FORMTEXT ?????Support that can be provided: FORMTEXT ?????Name: FORMTEXT ?????Relationship: FORMTEXT ?????Support that can be provided: FORMTEXT ?????Name: FORMTEXT ?????Relationship: FORMTEXT ?????Support that can be provided: FORMTEXT ?????Name: FORMTEXT ?????Relationship: FORMTEXT ?????Support that can be provided: FORMTEXT ?????Residential History and Domestic Information FORMTEXT ?Gather the information in this section through observations of the customer within their home and community settings as well FORMTEXT ? as from interviews with the Circle of Support Members. FORMTEXT ?Current living situation: FORMTEXT ?Describe the customer’s current living situation. How long has the customer lived at the current location? FORMTEXT ? Does the customer plan to remain at this location when he or she gets a job? FORMTEXT ? Is anything potentially putting this living arrangement at risk? FORMTEXT ? FORMTEXT ?????Home Management Skills: FORMTEXT ?????After observing the customer, describe the customer’s ability and willingness to perform such routine and non-routine activities in his or FORMTEXT ? her current living situation as cleaning, laundry, cooking, and personal hygiene. FORMTEXT ? Does the customer enjoy some activities more than others? FORMTEXT ? Are there any factors noted for which support may be needed for the customer to engage in employment? FORMTEXT ? FORMTEXT ?????Financial status: Describe the customer’s current financial status. Does the customer have a source of income other than Social Security benefits? FORMTEXT ?????How much does the customer need to earn per week or per month to meet his or her obligations? FORMTEXT ?????Benefit Status: Be sure to refer to benefits planning information provided by the VR counselor. FORMTEXT ? Does the customer receive Social Security Disability (SSDI) on his or her own record of disability, Social Security Childhood Disability FORMTEXT ? Benefits (CDB) and/or Social Security Disabled Widow/Widower Benefits? FORMTEXT ? FORMCHECKBOX Yes FORMCHECKBOX NoAmount: FORMTEXT ?????Does the customer receive another type of Social Security cash benefit (retirement or other survivor benefits)? FORMCHECKBOX Yes FORMCHECKBOX NoAre the Social Security benefits received under a parent’s Social Security number? FORMCHECKBOX Yes FORMCHECKBOX NoDoes the customer receive Supplemental Security Income (SSI)? FORMCHECKBOX Yes FORMCHECKBOX NoChildren and child care issues:Does the customer have children living at home? FORMCHECKBOX Yes FORMCHECKBOX NoDoes the customer have available and stable childcare? FORMCHECKBOX Yes FORMCHECKBOX NoInformation about the neighborhood: Describe the neighborhood where the customer lives and the general availability of services and supports to the customer. FORMTEXT ?Are there any support or safety issues in the neighborhood that may affect the customer’s work hours? FORMTEXT ?????What potential employers are within the customer’s neighborhood? FORMTEXT ?????Are there any unmet business needs that would support the development of a business by the customer? FORMTEXT ?????Community Resources and Supports FORMTEXT ?Enter community supports the customer is using and resources and supports the customer might be able to use FORMTEXT ? along with information regarding time frames for being able to access the service(s). FORMTEXT ? Examples include Medicaid Waivers (Community Living Assistance and Support Services, Home and Community-Based Services and Texas Home Living), FORMTEXT ?mental health service providers, transportation services, and Social Security Administration (SSA) work incentives. FORMTEXT ? Name of resource: FORMTEXT ?????Summary of service or supports: FORMTEXT ?????Contact information for resource: FORMTEXT ?????Name of resource: FORMTEXT ?????Summary of service or supports: FORMTEXT ?????Contact information for resource: FORMTEXT ?????Name of resource: FORMTEXT ?????Summary of service or supports: FORMTEXT ?????Contact information for resource: FORMTEXT ?????Name of resource: FORMTEXT ?????Summary of service or supports: FORMTEXT ?????Contact information for resource: FORMTEXT ?????Medical and Psychological History FORMTEXT ?Gather information for this section from the customer and Circle of Support members. FORMTEXT ? What medical conditions (seizures, pain, or substance abuse) are exhibited that must be addressed as an employment plan is developed? FORMTEXT ?????Are there any issues related to substance abuse? FORMTEXT ?????Has the customer been involved with the justice system? FORMTEXT ?????Describe all behaviors that have been labeled as challenging that might interfere with successful placement in a job. FORMTEXT ?????What “triggers,” antecedents, and/or stressors have interfered with the customer’s achievement of personal goals? FORMTEXT ?????Are there any strategies that appear to work for the customer in managing behaviors? FORMTEXT ?????Summarize the supports in the home that are anticipated, needed, planned, or in place. This includes daily living skills, child care, FORMTEXT ? benefits management, medical and psychological supports. Include who, what, where, when, and how. FORMTEXT ? FORMTEXT ?????Education: FORMTEXT ?Gather information for this subsection from the customer and Circle of Support members. FORMTEXT ?What is the highest grade completed by the customer? FORMTEXT ?????Enter the date the customer received his or her high school diploma or GED (if applicable): FORMTEXT ????? Vocational, Technical and/or Academic (college) Training (for example: Medical Records Technology) When(date completed) Skills gained FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????How will these skills be applicable to the potential jobs in wage employment? FORMTEXT ?????What environmental modifications or support strategies were in place (if any) to help the customer perform academic and/or training activities? FORMTEXT ?????Describe the customer’s three primary interests, preferences, and/or motivators FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Customer’s Volunteer and Work History FORMTEXT ?Gather information for this sub-section from the customer and Circle of Support members. FORMTEXT ? Use the following experience tables to describe the customer’s volunteer and work history in detail. FORMTEXT ? FORMCHECKBOX No work history to reportEmployer: FORMTEXT ?????Job title: FORMTEXT ?????Start date: FORMTEXT ?????End date: FORMTEXT ?????Earnings: FORMTEXT ?????Average Number of hours worked per week: FORMTEXT ?????Street address: FORMTEXT ?????Suite number or PO box number: FORMTEXT ?????City: FORMTEXT ?????State: FORMTEXT ?????ZIP code: FORMTEXT ?????Supervisor’s name: FORMTEXT ?????Phone: FORMTEXT ?????Email: FORMTEXT ?????Reason for leaving: FORMTEXT ?????Do you think this employer will give you a good reference? FORMCHECKBOX Yes FORMCHECKBOX NoDo you think that this employer would consider hiring you if volunteer or re-hiring you if you were paid employee? FORMCHECKBOX Yes FORMCHECKBOX NoRoles: FORMTEXT ? FORMCHECKBOX Technical FORMCHECKBOX Non-managerial FORMCHECKBOX Supervisory or managerial Number of employees supervised: FORMTEXT ?????Type of Employment: FORMTEXT ? FORMCHECKBOX Paid FORMCHECKBOX Volunteer FORMCHECKBOX Full-time FORMCHECKBOX Part-time FORMCHECKBOX Temporary or project FORMCHECKBOX Summer FORMCHECKBOX Contract FORMCHECKBOX Other: FORMTEXT ?????Average hours worked: FORMTEXT ?????Describe job duties: FORMTEXT ?????Employer: FORMTEXT ?????Job title: FORMTEXT ?????Start date: FORMTEXT ?????End date: FORMTEXT ?????Earnings: FORMTEXT ?????Average Number of hours worked per week: FORMTEXT ?????Street address: FORMTEXT ?????Suite number or PO box number: FORMTEXT ?????City: FORMTEXT ?????State: FORMTEXT ?????ZIP code: FORMTEXT ?????Supervisor’s name: FORMTEXT ?????Phone: FORMTEXT ?????Email: FORMTEXT ?????Reason for leaving: FORMTEXT ?????Do you think this employer will give you a good reference? FORMCHECKBOX Yes FORMCHECKBOX NoDo you think that this employer would consider hiring you if volunteer or re-hiring you if you were paid employee? FORMCHECKBOX Yes FORMCHECKBOX NoRoles: FORMTEXT ? FORMCHECKBOX Technical FORMCHECKBOX Non-managerial FORMCHECKBOX Supervisory or managerial Number of employees supervised: FORMTEXT ?????Type of Employment: FORMTEXT ? FORMCHECKBOX Paid FORMCHECKBOX Volunteer FORMCHECKBOX Full-time FORMCHECKBOX Part-time FORMCHECKBOX Temporary or project FORMCHECKBOX Summer FORMCHECKBOX Contract FORMCHECKBOX Other: FORMTEXT ?????Average hours worked: FORMTEXT ?????Describe job duties: FORMTEXT ?????Employer: FORMTEXT ?????Job title: FORMTEXT ?????Start date: FORMTEXT ?????End date: FORMTEXT ?????Earnings: FORMTEXT ?????Average Number of hours worked per week: FORMTEXT ?????Street address: FORMTEXT ?????Suite number or PO box number: FORMTEXT ?????City: FORMTEXT ?????State: FORMTEXT ?????ZIP code: FORMTEXT ?????Supervisor’s name: FORMTEXT ?????Phone: FORMTEXT ?????Email: FORMTEXT ?????Reason for leaving: FORMTEXT ?????Do you think this employer will give you a good reference? FORMCHECKBOX Yes FORMCHECKBOX NoDo you think that this employer would consider hiring you if volunteer or re-hiring you if you were paid employee? FORMCHECKBOX Yes FORMCHECKBOX NoRoles: FORMTEXT ? FORMCHECKBOX Technical FORMCHECKBOX Non-managerial FORMCHECKBOX Supervisory or managerial Number of employees supervised: FORMTEXT ?????Type of Employment: FORMTEXT ? FORMCHECKBOX Paid FORMCHECKBOX Volunteer FORMCHECKBOX Full-time FORMCHECKBOX Part-time FORMCHECKBOX Temporary or project FORMCHECKBOX Summer FORMCHECKBOX Contract FORMCHECKBOX Other: FORMTEXT ?????Average hours worked: FORMTEXT ?????Describe job duties: FORMTEXT ?????Based on what is known about the customer, did the jobs/volunteer experience appear to be a good match for the customer, why or why not? FORMTEXT ?????Based on these work and volunteer experiences, what has been learned about the customer’s skills, interests, and potential support need for: FORMTEXT ?What kind of work have you always wanted to do? FORMTEXT ?????What makes work appealing to you? FORMTEXT ?????What has kept you from doing that work? FORMTEXT ?????What kind of things are you good at? FORMTEXT ?????What have others said you are good at? FORMTEXT ?????What things are you proud of? FORMTEXT ?????What preferences do you have related to employment? (check all that apply and describe as appropriate) FORMTEXT ? FORMCHECKBOX Hours worked per week FORMTEXT ????? FORMCHECKBOX Hours on weekends FORMTEXT ????? FORMCHECKBOX Hours on weekdays FORMTEXT ????? FORMCHECKBOX Hours: describe the hours you are available to work FORMTEXT ????? FORMCHECKBOX Preferred wage FORMTEXT ????? FORMCHECKBOX Location of business (job) FORMTEXT ????? FORMCHECKBOX Health insurance FORMTEXT ????? FORMCHECKBOX Other benefits: Describe FORMTEXT ????? FORMCHECKBOX Other FORMTEXT ????? FORMCHECKBOX Other FORMTEXT ????? FORMCHECKBOX Other FORMTEXT ?????Informational Interview: FORMTEXT ?An informational interview is a meeting to learn about the real-life work experiences of someone in a job that interests you. FORMTEXT ? The informational interview must be completed with the customer interviewing someone other than the employment service provider and FORMTEXT ? must be in a field or company in which the customer is interested in pursuing for employment. FORMTEXT ?Time spent: FORMTEXT ?????Business name: FORMTEXT ?????Business location: FORMTEXT ?????Describe the setting. FORMTEXT ?????Description of tasks, skills performed, and information gained. FORMTEXT ?????Summary of the customer’s functional abilities observed during the observations. FORMTEXT ?????Summary of the customer’s functional limitations, challenges, and barriers observed during observations. FORMTEXT ?????Recommendation related to the customer’s pursuit of wage employment: FORMTEXT ?????Additional Comments: FORMTEXT ?????Work Skill Observations FORMTEXT ? FORMCHECKBOX Work Skill Observations, are not completed because an Environmental Work Assessment has been completed. At least three work skill observations allowing for demonstrations of skills, identification of motivators and preferences must be completed. FORMTEXT ? The work skill observations preferably should occur in an integrated setting. Each activity must occur in a different work environment. FORMTEXT ? The customer must be monitored closely by the supported employment specialist. Each observation must last long enough for the SES to get FORMTEXT ? enough information to determine whether the customer has the potential to perform the tasks FORMTEXT ? and what accommodations, training supports, and extended services and long-term supports are needed. FORMTEXT ? Supported employment customers must be observed at least an hour, but at least 3 hours is preferred at each work setting to determine FORMTEXT ? their employment support needs. After the customer participates in the work skill observations, record responses to the questions below. FORMTEXT ?Work Skill Observations Number 1 FORMTEXT ?Time spent: FORMTEXT ?????Business name: FORMTEXT ?????Business location: FORMTEXT ?????Describe the setting. FORMTEXT ?????Description of tasks, skills performed, and information gained. FORMTEXT ?????Summary of the customer’s functional abilities observed during the observations. FORMTEXT ?????Summary of the customer’s functional limitations, challenges, and barriers observed during observations. FORMTEXT ?????Recommendation related to the customer’s pursuit of wage employment: FORMTEXT ?????Additional Comments: FORMTEXT ?????Work Skill Observations Number 2 FORMTEXT ?Time spent: FORMTEXT ?????Business name: FORMTEXT ?????Business location: FORMTEXT ?????Describe the setting. FORMTEXT ?????Description of tasks, skills performed, and information gained. FORMTEXT ?????Summary of the customer’s functional abilities observed during the observations. FORMTEXT ?????Summary of the customer’s functional limitations, challenges, and barriers observed during observations. FORMTEXT ?????Recommendation related to the customer’s pursuit of wage employment: FORMTEXT ?????Additional Comments: FORMTEXT ?????Work Skill Observations Number 3 FORMTEXT ?Time spent: FORMTEXT ?????Business name: FORMTEXT ?????Business location: FORMTEXT ?????Describe the setting. FORMTEXT ?????Description of tasks, skills performed, and information gained. FORMTEXT ?????Summary of the customer’s functional abilities observed during the observations. FORMTEXT ?????Summary of the customer’s functional limitations, challenges, and barriers observed during observations. FORMTEXT ?????Recommendation related to the customer’s pursuit of wage employment: FORMTEXT ?????Additional Comments: FORMTEXT ?????Observations of physical activities: FORMTEXT ? After making observations throughout the assessment and using medical information provided by VRS to assist in documenting customer’s FORMTEXT ? preferences for any physical activity or environment and any physical abilities or limitations in this section. FORMTEXT ?Document physical deficits or abilities that may have implications for employment and support strategies in employment: FORMTEXT ?????Additional comments, if any: FORMTEXT ?????Observed cognitive skills: FORMTEXT ?Document cognitive deficits or abilities that may have implications for employment and support strategies: FORMTEXT ?????Describe the most effective way to teach the customer a new task. Describe the sequence of steps or FORMTEXT ? strategies that work best (for example, demonstrate first, and then have the customer try). FORMTEXT ?????What type of task monitoring or supervision seems to fit the customer’s preferences, tolerances, and ability to pursue wage employment FORMTEXT ?????Support Strategies: FORMTEXT ?????Additional comments, if any: FORMTEXT ?????Customer’s responses to social situations observed FORMTEXT ?Document social deficits or abilities and supports needs that may have implications for wage employment: FORMTEXT ?????Additional comments, if any: FORMTEXT ?????Observed Behaviors: FORMTEXT ? Describe the extent to which the customer is able and willing to express needs, ask questions, communicate with others, and use support strategies FORMTEXT ? Document implications for employment. FORMTEXT ?????Additional comments, if any: FORMTEXT ?????Work Environment and/or Work Culture Needs and Preferences FORMTEXT ? Are there any potential work environments that need to be avoided for health reasons, triggers for behavior issues, or preferences that FORMTEXT ? must be addressed as a non-negotiable employment condition? Document implications for: FORMTEXT ?????Support Strategies: FORMTEXT ?????List strengths the customer possesses that will support employability. FORMTEXT ? FORMCHECKBOX Transferable skills FORMCHECKBOX Intelligence and/or cognitive skills FORMCHECKBOX Physical abilities and/or capacity FORMCHECKBOX Stable work history FORMCHECKBOX Personality and/or interpersonal skills FORMCHECKBOX Academic skills FORMCHECKBOX Patterns of work behavior FORMCHECKBOX Family support and/or support system FORMCHECKBOX Community involvementOthers: FORMTEXT ?????List Skills and/or Tasks and/or Transferable Skills identified during informational interview, work skill observations, and other Discovery Activities: FORMTEXT ? Wage Employment: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Additional comments, if any: FORMTEXT ?????List employment opportunities and state their distance from your home. Include options for self-employment such as a business within a business. FORMTEXT ? FORMTEXT ?Wage EmploymentSelf EmploymentBusinessPossible employment opportunities FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ?????Additional comments, if any: FORMTEXT ?????Based on the information you have gathered, describe the environment and work culture that would be the best employment setting for the customer. FORMTEXT ?????Based on the information you have gathered, what should be avoided to identify the best employment setting for the customer? FORMTEXT ?????Describe such supports as social, communication, learning, environmental, assistive technology, or other supports potentially necessary to promote customer success at: FORMTEXT ?Wage Employment: FORMTEXT ?????Self-Employment (business ownership): FORMTEXT ?????Select any of the following for which the customer may need long-term supports. FORMTEXT ? FORMCHECKBOX Medication management FORMCHECKBOX Self-feeding at work FORMCHECKBOX Peer support group FORMCHECKBOX Showering and/or bathing FORMCHECKBOX Diet management at work FORMCHECKBOX Individual therapy FORMCHECKBOX Grooming and hygiene FORMCHECKBOX Meal preparation for work meals FORMCHECKBOX Job skills training for new job task FORMCHECKBOX Toileting at work FORMCHECKBOX Initiating coping techniques FORMCHECKBOX Employer communications FORMCHECKBOX Maintaining job aides FORMCHECKBOX Social Security reporting of earnings FORMCHECKBOX Monitoring of job performance FORMCHECKBOX Monitoring of the customer’s accommodations FORMCHECKBOX Other: FORMTEXT ????? FORMCHECKBOX Other: FORMTEXT ?????Record a brief summary of the customer’s support needs related to maintaining long-term, competitive, integrated employment within the community. 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 information recorded within the report above. FORMTEXT ? If you are not satisfied, do not sign. Contact your VR counselor. 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 ?????Supported Employment 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 Supported Employment Specialist as described in the VRSFP or Service Authorization; and FORMTEXT ?I signed my signature and entered the date below. FORMTEXT ?Supported Employment Specialist 1 Typed or Printed name: 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 attachedSupported Employment Specialist 2 Typed or Printed name: (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 AttachedSEA Meeting FORMTEXT ?This section is completed after the VR1641 SEA has been submitted to the VR counselor. FORMTEXT ?Date and time of SEA meeting: FORMTEXT ?????Names of those attending the SEA meeting: FORMTEXT ?????VRC accepts SEA as submitted: FORMCHECKBOX YES FORMCHECKBOX NO If no, date returned: FORMTEXT ?????VRC printed name: FORMTEXT ?????VRC signature: FORMTEXT ? XVRC Approval (Initials): FORMTEXT ?????VRC Approval date: FORMTEXT ?????Instructions: Review the VR1641. If the documentation meets the standards with all “Yes” answers and is approved by the VRC sign and date below. FORMTEXT ?If the documentation does not meet standards with any answer being “No” and/or is not approved by the VRC, indicate date form returned to provider, sign, and date the form. FORMTEXT ? FORMTEXT ?VRS 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 Supported Employment 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 CredentialSupported Employment Specialist’s Credential: FORMTEXT ?UNTWISE website or attached VR3490 verifies, for the dates of service, the Supported Employment 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 Supported Employment 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 Supported Employment Specialist listed above maintained one of the following: FORMTEXT ? 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 NoWhen applicable, verify a copy of an approved VR3472 is attached to the report? FORMCHECKBOX NA FORMCHECKBOX Yes FORMCHECKBOX NoVerified a total of three Work Skill Observations were completed in different work settings. FORMTEXT ? FORMTEXT ? FORMCHECKBOX Yes FORMCHECKBOX NoVerified the SEA Review Meeting was held FORMCHECKBOX Yes FORMCHECKBOX NoVerified all signatures are present on the form. FORMCHECKBOX Yes FORMCHECKBOX NoIf section C of the SEA indicates an Environmental Work Assessment was completed prior to the SEA, verified that the SEA rate was prorated by use of appropriate specification listed in the Services Authorization.. FORMTEXT ? FORMCHECKBOX Yes FORMCHECKBOX NoVerified that the VR1641 was submitted with invoice with appropriate dates of service. FORMCHECKBOX Yes FORMCHECKBOX NoVerified that any additional requirements of the SEA that are noted in the “special comments” section of the service authorization were met. 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 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 the VR1641 identifies the customer’s interest, assets and abilities in both work and non-work areas summarizing how the customer can be represented to potential employers. FORMTEXT ? FORMCHECKBOX Yes FORMCHECKBOX NoVerified the VR1641 identifies one or more appropriate job matches for the customer. FORMCHECKBOX Yes FORMCHECKBOX NoVerified how the employment goal for the customer was gained and how it aligns with the customer’s interest, assets and abilities. FORMCHECKBOX Yes FORMCHECKBOX NoVerified specific support needs, interventions and Extended Services the customer will need to maintain successful employment. FORMCHECKBOX Yes FORMCHECKBOX NoVerified the supported employment specialist collected information through customer observations held at multiple occasions and locations. FORMTEXT ? FORMCHECKBOX Yes FORMCHECKBOX NoVerified the information in all sections of the form are unique and individualized for the customer. FORMCHECKBOX Yes FORMCHECKBOX NoVerified the information in the VR1641 is accurate by consulting with the customer, guardian and/or parent and/or the customer’s Circle of Support members. 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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