/ Texas Workforce Commission
Vocational Rehabilitation Services
Work Experience Training Report
General Instructions
Follow the instructions below when completing this form and follow the associated procedures:
  • Complete one form for each staff person working with the customer.
  • Record the goals related to services to be delivered by the work experience trainer transferring from the Work Experience Referral and/or service authorization.
  • Record a narrative description of the services provided by the work experience trainer and of thecustomer’s performance as it relates to the goal(s) addressed in the session.
  • The Work Experience Trainer completes the Work Experience Training Report and the signatures are collected after the all Work Experience Training services have been provided.
  • Complete the form electronically (on the computer), making certain all questions are accuratelyand thoroughly answered and all applicable standards have been met before submitting by fax, encrypted email, or mailing with an invoice for payment.

Customer Information
Customer name: / VRS case ID:
Service authorization (SA) number:
Work Experience Training Goals
Individual Work Experience Training / Group Work Experience Training
Instructions: In the first column below, indicate with an “x” if the goal is identified for the customer.
If the goal is selected for the customer, individualize the goal by entering “Potential Areas of Focus.”
Yes No /
  1. Assist the customer in learning skills necessary to meet the work experience site’s expectations.

Potential Areas of Focus:
Yes No /
  1. Identify performance issues and implement a plan of action to improve performance of the customer.

Potential Areas of Focus:
Yes No /
  1. Evaluate and make recommendations for support and training needs, accommodations, adaptive equipment, and job aids to ensure safe and efficient performance by the customer at the work experience’s site

Potential Areas of Focus:
Yes No /
  1. Establish support and training needs, accommodations, aids necessary to remove barriers to ensure successful work experience for the customer and site.

Potential Areas of Focus:
Yes No /
  1. Observe, monitor and make recommendations related to the customer’s performance of tasks, use of aids and need for accommodations to remove barriers for successful engagement in the work experience for the customer.

Potential Areas of Focus:
Yes No /
  1. The work experience trainer will gradually reduce the time spent with the customer at the work experience site, as the customer becomes better adjusted and more independent.

Potential Areas of Focus:
Yes No /
  1. Additional goal(s):

Progress Log
Instructions:
  • For each entry on the Progress Log Section: Date Column: enter the date the service provided (xx-xx-xx).
  • Time Column: enter start time and end time of session rounding numbers off to closest quarter hour (.25 = 15 minutes, .50 = 30 minutes, .75 = 45 minutes, and 1.0 = 60 minutes.) Use 0 for non-billable notation.
  • Number of Goal Column: record goal numbers listed below for all goals addressed in the session.
  • Describe the Contact or Service Provided column: record a narrative description of the services provided by the work experience trainerand of the customer’s performance of skills as it relates to goal(s).
  • Total Time of Sessions cell: add total time of all services provided. Add any additional comments as appropriate.

Date / Time
(Start–End)
(a.m.–p.m.) / Total time of session / Number of each goal addressed / Describe the contact or service provided.
Total time of sessions:
Additional Comments
Additional comments:
Signatures
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 Trainer Signature (Required for all providers)
By signing below, I, the Work Experience Trainer, certify that:
  • the above dates, times, and services are accurate;
  • I documented the services and information described above in this form;
  • 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 Trainer typed name: / Work Experience Trainer 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 VR Standards for Providers when delivering the service and;
  • I maintain the staff qualifications, including the UNTWISE credential, required for a director, as described in the VR 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 work experience trainer listed above is
NOT Credentialed
Credentialed as a job skills trainer
Maintains BEI, RID, SLPI required for Premium
Endorsed in Other Specialization - specify:
  • If the director or work experience trainer is not credentialed, is an approved DARS3490, Temporary Waiver of CRP Credentials, attached to the invoice?
/ Yes No N/A
  • If yes, does the DARS3490 approve the director and/or work experience trainer for the date of services?
/ Yes No N/A
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.
Date:______
  • Enter the date a case note was made to document the return of invoice and required form(s)
Date: ______
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 VR Standards for Providers, and/or the SA / Yes / No
Verified the appropriate service(s) was provided as stated in the VR Standards for Providers and/or the SA / Yes / No
Verified the form indicates the work experience trainer provided training based on goals and focus areas on the DARS1600, Work Experience Referral, service authorization. / Yes / No
Verified the progress log contains the entries of date of service, start time and end time of session, total time of session and goal(s) addressed in session. / Yes / No
Verified the form contains narrative descriptions of the services provided by work experience trainer and customer’s performance of skills / Yes / No
Verified the hours recorded on form are accurate and added correctly with total hours matching attached invoice and are approve by a service authorization / Yes / No
Verified the hours has decreased, as appropriate, as the customer becomes better adjusted, more independent and no longer needs training supports. / 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:

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