Vocational Rehabilitation Services
Work ExperienceMonitoring Report
The Work Experience Specialist followsthe instructions below when completing this form.
- Complete the form electronically (on the computer) after the placement has been established and answer all questions.
- Write summaries in paragraph form in clear, descriptive English. Leave no blanks. Enter N/A if not applicable.
- Print the form, obtain signatures, and submit.
- If the customer’s status requires services to switch to Work Experience Training, the Work Experience Services provided are recorded and the payment rate will be prorated.
- Make certain that all standards are met before submitting this form with an invoice for payment.
General Information
Customer name: / VRS case ID:
Service authorization (SA) number(s):
Start date of services included in report: / End date of services included in report:
Customer’s Work Experience Site Information
Company name:
Street address (include suite number, if any):
City: / State: / ZIP code:
Main phone number: () / Company website:
Supervisor’s (or contact person’s) name:
Supervisor’s (or contact person’s) title:
Supervisor’s (or contact person’s) direct phone number: ()
Supervisor’s email address:
Select the best method and time to contact the customer’s supervisor:
Phone / Email / In person / Day and time:
Describe the skills, duties and responsibility the customer will be performing at the Work Experience Site.
Work Experience Start Date: / End Date:
Customer’s Projected Work Experience Schedule (days, hours):
Customer’s Earnings, if any (hourly wage, stipend, etc.): None Yes
If yes, describe:
Work Experience Hours Completed by the Customer
For each week of the Work Experience, record the Sunday–Saturday of the week as the date, record the number of hours the customer participated in the Work Experiences each day of the week, and total the hours worked for the week.
At the completion of each report, total the hours the customer participated for all weeks of the month and adjust the record comments as appropriate.
Week / Date:
(Sun.–Sat.) / Sunday / Monday / Tuesday / Wednes-day / Thursday / Friday / Saturday / Total hours
1
2
3
4
5
Total hours for month
Summary of Work Experience Visits and Contact
Record and summarize each weekly check-in and visit made with the customer or Work Experience site. If necessary, attach another page with additional information.
Date: Visited with:Customer Work Experience staff Both
Type of visit: Face to face Check-in contact
Summary of visit or contact:
Date: Visited with:Customer Work Experience staff Both
Type of visit: Face to face Check-in contact
Summary of visit or contact:
Date: Visited with:Customer Work Experience staff Both
Type of visit: Face to face Check-in contact
Summary of visit or contact:
Date: Visited with:Customer Work Experience staff Both
Type of visit: Face to face Check-in contact
Summary of visit or contact:
Date: Visited with:Customer Work Experience staff Both
Type of visit: Face to face Check-in contact
Summary of visit or contact:
Date: Visited with:Customer Work Experience staff Both
Type of visit: Face to face Check-in contact
Summary of visit or contact:
Date: Visited with:Customer Work Experience staff Both
Type of visit: Face to face Check-in contact
Summary of visit or contact:
Date: Visited with:Customer Work Experience staff Both
Type of visit: Face to face Check-in contact
Summary of visit or contact:
Customer’s Performance-Evaluation of Soft Skills
Gain information from the staff at theWork Experience site and from observations made related to the customer’s soft skills then rate the customer on the following criteria.
Soft Skill / Excellent:
meets expectations / Fair:
meets expectations most of the time / Poor:
does not meet expectations / Not applicable:
not addressed
Ability to learn
Accuracy and quality of work
Accepts supervision
Adaptability
Admits mistakes
Appearance, dress, and hygiene
Asks for help and clarification as needed
Attendance
Communication
Cooperativeness
Co-worker relations
Dependability
Handles stress
Initiative
Listens and pays attention
Motivation
Maintains eye contact
Quantity of work
Refrains from unnecessary social interactions
Respects the rights and privacy of others
Service to customers
Timeliness and deadline achievement
Additional comments on soft skills, if any:
Customer’s Performance-Evaluation of Hard Skills
Gain information from the staff at the Work Experience site and from observations made related to the customer’s Soft Skills then rate the customer on the following criteria.
Hard skills
Add hard skills, job skill tasks, and responsibilities of the Work Experience. / Excellent
meets expectations / Fair
meets expectations most of the time / Poor
does not meet expectations / Not applicable
not addressed
Additional comments on hard skills, if any:
Summary of Customer’s Work Experience
Is the customer still achieving all non-negotiables and 50% of the negotiables Work Experience Conditions outlined in the DARS1601? Yes No
If no, describe why the Work Experience Condition(s) is no longer being achieved and if the lack of the employment condition is negativelyaffecting the customer.
Summarize the assistance, training and supports provided the first week of the Work Experience to:
Customer:
Business:
Record total time spent at worksite:
Describe how the customer has adjusted to his or her work experience including any problematic issues or concerns that emerged and how they were addressed.
Describe any accommodations, compensatory techniques and specials training needs required by the customer.
Summarize any recommendation related to future training that can enhance or improve the customer’s skills.
Additional Comments
Additional comments, if any:
Signatures
Customer Signature
By signing below, I, the customer or authorized representative, agree with the information recorded within the report above. If you are not satisfied, do not sign. Contact your VR counselor.
Customer’s signature:
X / Date:
Customer’s legally authorized representative’s signature, if any:
X / Date:
Provider Qualifications
Type of Provider: / Traditional-bilateral contractor / Transition Educator / Non-traditional
Traditional-bilateral contractor must complete the provider qualification section below. This section is not applicable to Transition Educator and Non-traditional providers.
Qualifications / Proof of Qualification / Verified by TWS-VRS
Specify UNTWISE Credential: / UNTWISE Credential Number:
if no, DARS3490-Waiver Proof Attached / Yes No N/A
Specify UNTWISE Endorsement:
N/A / UNTWISE Endorsement Number: / Yes No N/A
Select: RID BID
SLIPI N/A / RID/BID/SLIPI Number:
Proof Attached / Yes No N/A
Other: / Number: Proof Attached / Yes No N/A
Work Experience Specialist Signature (required for all providers)
By signing below, I, the Work Experience Specialist, certify that:
- The above dates, times, and services are accurate;
- I personally completed the Work Experience Monitoring Report collecting information about the customer through interviews with the Work Experience Site employees and supervisors and/or through observations of the customer at the Work Experience Site;
- I documented the services and information described above in this form;
- I meet with the customer and/or Work Experience staff weekly with at least one visit face to face meeting with the customer and the Work Experience Supervisor or contact;
- All Outcomes Require for Payment, as described in the TWC VR Standards for Provider and Service Authorization(s) were met;
- The customer’s and/or customer’s legally authorized representative’s signature on this form was gained on the date stated in the date field of the form;
- I handwrote my signature and the date below; and
- I maintain qualification as stated in the Standards or Service Authorization for the services provided and documented on this form.
Work Experience Specialist typed name: / Work Experience Specialist signature:
X / Date:
Director Credentials and Signature
Required for Traditional-Bilateral Contractors
By signing below, I, the Director, certify that:
- I handwrote my signature and the date below; and
- I ensure that the staff meets the qualifications and met the requirements in the Standards for Providers when delivering the service and;
- I maintain the staff qualifications, including the UNTWISE credential, required for a director, as described in Standards for Providers and/or service authorization.
Qualifications / Proof of Qualification / Verified by TWS-VRS
Specify UNTWISE Credential: / UNTWISE Credential Number:
if no, DARS3490-Waiver Proof Attached / Yes No N/A
Director’s typed name: / Director’s signature:
X / Date:
VRS Use Only—
Date Form Submitted by Provider:
Date Form Received by TWS-VRS Office:
Verification of Qualifications
The UNT website verifies that the director listed above is
NOT Credentialed Credentialed as a CRP Director
The UNT website or supporting documentation verifies the Vocational Adjustment Trainer listed above is
NOT Credentialed
Credentialed as a Vocational Adjustment Training Specialist
Maintains BEI, RID, SLPI required for Premium
Endorsed in Other Specialization Specify
- If the director or vocational adjustment trainer is not credentialed, is an approved DARS3490, Temporary Waiver of CRP Credentials, attached to the invoice?
- If yes, does the DARS3490 approve the director and/or vocational adjustment trainer for the dates the services?
If unable to verify the credentials, complete the following:
- Enter the date a copy of the submitted invoice, report and DARS3460 was sent to provider to notify the staff did not meet the qualification as defined in the Standards for Providers and/orSA.
- Enter the date a case note was made to document the return of invoice and required form(s)
Printed name of VRS staff member making verifications: / Date verified:
Approval of the Report
Verified that the report is accurately completed per form instructions, in the Standards for Providers, and/or the SA / Yes
No
Verified the appropriate service(s) was provided as stated in the Standards for Providers and/or the SA / Yes
No
Verified the work experience placement site information is documented on the form / Yes
No
Verified the customer’s hours worked or volunteered are recorded on the form / Yes
No
Verifieda minimum, one face-to-face meeting with the customer and work site supervisor for the reporting period with form entries for each visit summarizing supports, training and/or the customer’s job performance / Yes
No
Verified a minimum of weekly “check-in” contact with the customer for the reporting period with form entries for each visit summarizing supports, training and/or the customer’s job performance / Yes
No
Verified the customer maintained Work Experience Job Title, performing skills, tasks and responsibilities, achieving all non-negotiable and 50% of the negotiable conditions as outline in the DARS1601 or Verify a description of why the skills, tasks and responsibilities, all non-negotiable and 50% of the negotiable conditions as outline in the DARS1601 are no longer being meet is present and appropriate / Yes
No
Verified the customer’s soft and hard skills were evaluated and documented on the form for the reporting period / Yes
No
Verified the customer’s satisfaction with the training through signature on the form and/or by VR staff member contact with customer / Yes
No
Verified that the appropriate fee(s) was invoiced / Yes
No
If any question above is answered “No,” complete the following:
- Enter the date a copy of the submitted invoice, the report and DARS3460 to notify the provider the service delivery or report did not meet the requirements as described in the Standards for Providers and/orSA. Date:
- Record a case note to document the return of invoice and required form(s)Date:
Report: Approved Sent back to provider
Comment (if any):
Printed name of VR staff member making verification: / Date Verified:
DARS1603 (10/17)Work Experience Monitoring ReportPage 1 of 7