Vocational Rehabilitation Services
Supported Employment Service Plan – 1
Plan and Benchmark Report
Instructions
- The Supported Employment Service Plan (SESP) Part 1 planning meeting is led by the customer with assistance from the team in facilitating the planning meeting.
- VRS staff members complete the DARS1613A, DARS1613B, and DARS1613C during the SESP—Part 1 planning meeting.
- SESP—Part 1 all parts must be completed before any service can be provided.
- When a SESP—Part 1 needs to be updated for any reason, the updated SESP—Part 1 must be completed before any days are counted towards the achievement of a benchmark. Examples of when a SESP—Part 1 needs to be updated include: the Targeted Job Tasks change, or a non-negotiable Employment Conditionbecome negotiable, or 100% of the non-negotiable Employment Condition and at least 50% of the negotiable Employment Conditions cannot be achieved with the placement. The VRS staff and the customer will make the final decisions related to changes to the SESP—Part 1related to the Employment Conditions, Targeted Job Tasks, and Extended Service needs.
- All signatures for the DARS1613A will be collected at the conclusion of the planning meeting and initialed on 1613B & 1613C.
- All signatures for the DARS1613B, C, & D in the Signatures for Benchmark Status Reports Section will be collected at the completion of each benchmark.
- VRS staff members provide encrypted electronic copy (MSWord document – not the scanned version) of the completed SESP—Part 1 (1613A, B, C, & D) formto the provider after the planning meeting. This is the form that the Supported Employment Specialist (SES)will update at the achievement of each benchmark.
- At Benchmarks 2–6, the SES updates the SESP—Part 1 to document the current status of Targeted Job Tasks, Employment Conditions, Extended Services and Hours Worked by the Customer. As the form is submitted, the previous recorded information for each benchmark should remain on the form. Eligible Premiums and Indication of Achievement at 90 Days of PlacementSection should be updated at Benchmark 6. New signatures must be gained at each benchmark.
- The SES submits the invoice the day after achievement of the benchmark (for example, the day after the completion of working for 5 days/shifts, 29th day, 57th day)
Customer Identification
Customer name: / VRS Case ID: / Associated service authorization number:
Benchmark Information
Indicate at each submission one benchmark or reason the form is being completed (select one):
Benchmark 1b Benchmark 2 Benchmark 3 Benchmark 4 Benchmark 5 Benchmark 6 Other(explain):
MUST COMPLETE DARS 1613A,B, & C FOR PLAN TO BE COMPLETE
Employment Conditions
Instructions:
- Record all employment conditions in measurable terms and indicate whether the employment conditions are either “negotiable” or “non-negotiable.” Be sure to address support needs and any mandatory commitments that must be considered for the customer to maintain a long-term job placement.
- Supported Employment Specialist will select the checkbox under the appropriate benchmark to indicate that the employment condition was achieved. If the employment condition was not achieved, the box will not be selected.
Negotiable conditions are those that a customer would like the CRP to consider in the job search. / Instructions: Supported Employment Specialist Records achievement of each Employment Condition at each Benchmark timeframe
Achieved at Benchmark:
Employment Conditions / Negotiable / Non-negotiable / 2 / 3 / 4 / 5 / 6
- Enter minimum and maximum hours to work per week:
- Enter minimum and maximum hours to work per shift:
- List weekday hours available:
Monday:
Tuesday:
Wednesday:
Thursday:
Friday:
- List Weekend hours available:
Saturday:
Sunday:
- Earnings cannot be less than (Choose one)
- Distance and time willing to travel to and from work:
- Transportation method:
- Mandatory commitments that must be accommodated:
Not an option
Not an option
Not an option
- Job site adaptation(s) and other support needs:
- Other:
- Other:
Targeted Job Tasks
Instructions:
- List all job tasks identified by the team that the customer can currently or potentially perform and that the customer is willing to perform.
- The supported employment specialist selects the box under the appropriate benchmark to indicate that the Job Task(s) was achieved. If the Job Task(s) was not achieved, the box will not be selected.
Achieved at Benchmark:
Note: The placement must meet at least one targeted job task listed in the SESP--Part 1. The Supported Employment Specialist records achievement of up to 10 Job Skill Tasks and the benchmarks where they are achieved below. / 2 / 3 / 4 / 5 / 6
Potential Employers and Business Types
Instructions: List each potential employer or business contact person’s information, including name, phone number, and email, as applicable, as well as the potential targeted job tasks identified by the team that the customer can currently or potentially performand that the customer is willing to perform at the business if he or she gains employment.
Employer or Business Name / Contact Information / Potential Task (use numbers under the “Targeted Job Tasks”)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Initials at time of Plan
By initialing in the appropriate space below, I am agreeing and certifying my agreement with the plan as developed on this date:
Customer’s Initials: / Customer Representative’s Initials:
VRS Counselor’s Initials: / Provider SES’s Initials:
Employment Services Premiums
Eligible for:
(completed at Plan) / Premium Achieved:
(documented at completion of Benchmark 6) / VRS ONLY –
Verified for Payment
Autism Services Premium Yes No / Autism Services Premium Yes No / Yes No N/A
Initials:
Criminal Background Premium Yes No / Criminal Background Premium Yes No / Yes No N/A
Initials:
Deaf Services Premium Yes No / Deaf Services Premium Yes No
(If yes, attach a copy of the certification.) / Yes No N/A
Initials:
Wage Premium Yes No / Wage Premium Yes No
(If yes, submit a copy of a detailed pay statement.) / Yes No N/A
Initials:
Professional Placement Premium Yes No / Professional Placement Premium Yes No
(If yes, submit proof of the degree requirement.) / Yes No N/A
Initials:
Other Yes No / Other Yes No / Yes No N/A
Initials:
Other Yes No / Other Yes No / Yes No N/A
Initials:
MUST COMPLETE DARS 1613A, B, & C FOR PLAN TO BE COMPLETE
Signatures at Benchmark
Customer Signature
By signing below, I, the customer or the legally authorized representative (when applicable) understand, agree, and certify the job I have meets 100% Non-negotiable and at least 50% negotiable conditions with at least one targeted job task. I am satisfied with these conditions, job tasks, and services. If I am not satisfied I will not sign the form and I will contact my VRS counselor.
Customer’s signature at plan:
X / Date:
Customer’s legally authorized representative’s signature:
X / Date:
By signing below, I, the provider, agree with the Employment Conditions, Job Tasks, Potential Employers and Business Types, and Extended Services stated on DARS 1613A,B, & Cand have followed the plan when developing the job for the customer. I certify the job meets 100% Non-negotiable and 50% negotiable conditions with at least one targeted job task and by the customer’s signature above, the customer or legally authorized representative is satisfied with these conditions, job tasks, and services.
Supported Employment Specialist signature at Plan:
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 BEI
SLIPI N/A / RID/BEI/SLIPI Number:
Proof Attached / Yes No N/A
Other: / Number: Proof Attached / Yes No N/A
Supported Employment Specialist Signature (Required for all providers)
By signing below, I, the Supported Employment Specialist, certify that:
- the above dates, times, and services are accurate;
- I personally provided services recorded on this form and associated invoice;
- I documented the information on the form for the customer represented on this form;
- The customer’s and/or customer’s legally authorized representative’s signature on this form was obtained on the date stated in the date field of the form;
- I handwrote my signature and the date below; and
Supported Employment Specialist’s typed name: / Supported Employment Specialist’s 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:
Date Form Submitted by Provider:
Date Form Received by TWS-VRS Office:
VRS Use Only—Verification of CRP’s Staff UNT Credentials and Endorsements
The UNT website verifies that the CRPs staff person listed above is
NOT Credentialed Credentialed in Supported Employment
Endorsed in Autism Specialization Other (such as BEI, RID, SLPI)
Endorsed in Other Specialization Endorsed in Other Specialization
- If the supported employment specialist (SES) is not credentialed, is an approved DARS 3490, Temporary Waiver of CRP Credentials, attached to the invoice?
- If yes, does the DARS 3490 approve services with the correct service dates?
VRS Use Only—Verification of CRP Director’s UNT Credentials
The UNT website verifies the CRPs director person listed above is NOT Credentialed Credentialed as Director
- If the director is not credentialed, is an approved DARS 3490, Temporary Waiver of CRP Credentials, attached to the invoice?
- If yes, does the DARS 3490 approve services with the correct service dates?
Printed name of VRS staff member making verification: / Date verified:
If unable to verify the credentials, complete the following:
- Enter the date a copy of the submitted invoice and DARS 1612 was returned to the CRP with written notification that CRP staff person or director did not meet one of the credential criteria required.
- Enter the date a case note was made to document the return of invoice and required form(s)
Instructions:
Review the DARS1613 A, B, C, and/or D. If the documentation meets the standards with all “Yes” answers and is approved by the VRC sign and date below. 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.
VRS Use Only—VRS Approval of the DARS 1613B
Verified the DARS1613B is accurately completed per form instructions and the standards for providers. / Yes No
Verified that the DARS1613B was submitted with invoice with appropriate dates of service. / Yes No
If Benchmark 1A: Supported Employment Assessment (SEA) was prorated because the Environmental Work Assessment had been completed prior to the SEA and the case is eligible for the Autism Premium verified that theAutism Premium at completion Benchmark 1b was prorated by use of appropriate specification listed in the Services Authorization. / Yes No N/A
At Benchmark 1b and anytime the DARS1613B or C was updated, verified all signatures/initials on forms. / Yes No N/A
At Benchmark 1b and anytime the DARS1613B was updated, verified the Employment Conditions are written measurable terms / Yes No N/A
At Benchmark 1b and anytime the DARS1613B was updated, verified the Employment Conditions are determined to be either negotiable or non-negotiable. / Yes No N/A
At Benchmark 1b and anytime the DARS1613B was updated, verified Targeted Job Task(s) section of the DARS1613B is completed. / Yes No N/A
At Benchmark 1b and anytime the DARS1613 was updated, verified the Potential Employers and Business Types section of the DARS1613B is completed. / Yes No N/A
At benchmarks 2, 3, 4, 5, and 6, verified 100% of the Non-negotiables Employment Conditions is achieved with the job gained by the customer. / Yes No
At benchmarks 2, 3, 4, 5, and 6, verified at least 50% of the Negotiable Employment Conditions is achieved with the job gained by the customer. / Yes No
At benchmarks 2, 3, 4, 5, and 6,verified at least one Targeted Job Task(s) recorded on the DARS1613B is achieved with the job gained by the customer. / Yes No
At benchmarks 1b, 2, 3, 4, 5, 6 and anytime DARS1613B is updated, verified the customer and any VRS representative for the customer are in agreement with information on the DARS1613B. / Yes No
At benchmarks1b, 2, 3, 4, 5, 6 and anytime DARS1613B is updated, verified all signatures are present on the form. / Yes No
At benchmarks 2, 3, 4, 5, 6 and anytime DARS1613B is updated,verified that all additional requirements of the placement noted in the “special comments” of the service authorization (SA) were met. / Yes No
At Benchmark 6, when if any of the following eligible Employment Premium Services authorized by a Service Authorization and invoiced requirements verified?
Autism Services Premium requirement met / Yes No N/A
Criminal Background Premium requirement met / Yes No N/A
Deaf Services Premium requirement met / Yes No N/A
Professional Placement Premium requirement met / Yes No N/A
Other Services Premium requirement met / Yes No N/A
Other Services Premium requirement met / Yes No N/A
Wage Premium requirement met / Yes No N/A
If any question above is answered “No,” complete the following:
- Send a copy of the submitted invoice and this form to the CRP with DARS3460 notifying the service did not meet the requirements as described in the Standards for Providers.
- Record a case note to document the return of invoice and required form(s)
Report: Approved Sent back to provider
Printed name of VRS staff member making verification: / Date Verified
Comment (if any):
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