Vocational Rehabilitation Services
Supported EmploymentJob Stability Justification Summary
General Instructions
Follow the instructions below when completing this form:
- Information on the form must be submitted electronically and be accurate and complete.
- The supported employment specialist (SES) will record an answer to all questions.If a question or section does not apply, enter “Not Applicable” or N/A and explain why.
- Write narrative summaries in paragraph form in clear, descriptive English.
- Indicate how and when you collected the information in the narrative summaries.For example,“the supported employment specialist collected the information through discussion with thecustomer’s supervisor, or the supported employment specialist observed the customer performing (skill or task) at the job site on March 1, 2014.”
- Before submitting with an invoice for payment, review the document to ensure that all questions have been answered, the Standards for Providers outcomes have been met and all quality criteria have been met.
- Submit invoice for payment no sooner than the day after achievement of the benchmark(for example, the day after the completion of working for 5 days/shifts, the 29thday, or the 56th day).
Select which benchmark is being documented.
Benchmark 5: Job StabilityOther, explain
Customer Identification
Customer’s name: / VRS Case ID:
Employment Information
Note: If the customer is placed in any new subsequent positions or jobs, a new DARS1614A & B, Supported Employment Services Plan (SESP)—Part 2, must be completed and signed by all parties.There must be a minimum of 30 days in any new subsequent position or job before “Stability” can be determined.
Customer’s job title: / First day worked in current placement:
// (month/day/year)
Average number of hours the customer works weekly:
Hourly wage:
Weekly gross earnings:
Original (first) placement: / Yes / No
New placement: (must submit a new DARS1614 with this DARS1616 if a new placement has been made after achievement of Benchmark 4) / Yes / No
Complete the information below only if the customer is placed in a new job.
Updated SESP—Part 2 submitted for new placement? / Yes / No
First placement: Start date: // (month/day/year)
End date: // (month/day/year)
Second placement: Start date: //
End date: //
Service Delivery Information Support Summary
The customer has worked at least 56 cumulative calendar days. / Yes / No
Date the customer achieved “Stability Status” as defined in the standards for providers. / //
Employment was verified through, select one:
Employer contact Customer contact Directly observing the customer at work
Other. Describe:
Briefly describe the customer’s job duties and his or her ability to perform them:
Identify any job duties, tasks, or production standards adjustments that have been removed or added to the position’s job description to make the position customized for the customer:
Are the customer’s job description changes documented in writing with the employer? / Yes / No / N/A
Describe evidence to support that the employer is satisfied with the customer’s job performance:
Describe evidence to support that the customer and, if applicable, the customer’s representative (family member or other) are satisfied with the job and the work environment:
Describe what types, methods, and strategies are set up for future training needs of the customer if new job duties are introduced, or if changes or issues occur with the customer’s production standards for providers:
Needed Accommodations
Are there necessary modifications and/or accommodations made at the worksite to ensure the customer’s success? / Yes / No / N/A
If you answered yes, identify below all physical, cognitive, or mental requirements or environmental demands of the job position that have been accommodated to make the position customized for the customer. Describe the accommodation or solution to the requirement.
Requirement or Demand
Related to the Customer’s Employment / Accommodation or Solution Related to the Requirement or Demand
1.
2.
3.
4.
5.
If you answered No or N/A, record why:
Are the customer’s accommodations documented with the employer? / Yes No NA
If Yes, describe when and where it was documented with the employer. If No or N/A, document why: / Yes No NA
Does the customer have reliable transportation to and from work, and is a backup transportation plan in place? / Yes No NA
If you answered yes, describe the primary and secondary transportation plan. If you answered No or N/A, explain why.
Briefly describe the amount and types of services you provided to the customer to help him or her maintain employment:
Additional comments:
Job Stability Meeting
Date of meeting:
Place of meeting:
Who attended the meeting? Select from the following
Customer Customer’s Representative VR Counselor SE Specialist
Extended Supports Provider Other: Other:
Signatures
VR Counselor SignatureI, the VR Counselor confirm a job stability meeting was held as per the information above, and the customer, the SE specialist, and I agree the customer has met the criteria for job stability.
VR Counselor written or typed name: / VR Counselor’s signature:
X / Date:
Customer Signature
By signing below, I, the customer or legally authorized representative, am satisfied and certify that the information recorded on this form is accurate. If you are not satisfied, do not sign and contact the 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 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
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
- I maintain the staff qualifications, including the UNT WISE credential, required for a Supported Employment Specialist, as described in Standards for Providers and/or Service Authorization.
Supported Employment Specialist typed name: / Supported Employment 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:
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 yes, does the DARS 3490 approve services with the correct service dates?
VRS Use Only—Verification of CRP’s Director UNT Credentials
The UNT website verifies that the CRP director listed above is
NOT Credentialed Credentialed as Director
- If the director is not credentialed, is an approved DARS3490, Temporary Waiver of CRP Credentials, attached to the invoice?
- If yes, does the DARS3490 approve services with the correct service dates?
If unable to verify the credentials, complete the following:
- Enter the date a copy of the submitted invoice and DARS1616A was returned to the CRP with written notification that CRP staff person 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)
Printed name of VRS staff member making verification: / Date verified:
VRS Use Only—VRS Approval of the DARS 1616 A & B
Instructions:
Review the DARS 1616. 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 when the form was returned to the provider, sign, and date the form.
Verified that the DARS1616A is accurately completed per instructions on form and the standards for providers. / Yes No
Verified that the customer has been employed at least 56 days from date of placement. / Yes No
Verified that the Job Stability meeting was held and documented / Yes No
Verified that the DARS1616A was submitted with invoice with appropriate dates of service. / Yes No
Verified that extended services and/or long term supports are in place and working. / Yes No
Verified that on-site job-skills training is completed. / Yes No
Verified that customer, parent and/or guardian, and employer continue to be satisfied with the placement. / Yes No
Verified that wages are at or above minimum wage but not less than the customary or usual wage paid by the employer for the same or similar work performed by people who do not have disabilities. / Yes No
Verified that the customer is working in a “competitive integrated work setting” as defined in the standards for providers. / Yes No
Verified that any additional requirements of the placement noted in the “special comments” of the service authorization were met. / Yes No
At benchmark 5 and 6, the Extended Services section of the DARS1613C has had all Extended Services providers verified by VRS with the VRS only section recording all Yeses. / Yes No
At Benchmark 6, when any of the following eligible Employment Premium Services authorized by a Service Authorization and invoiced requirements verified? / Yes No N/A
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 requirementsas 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 / Date Sent Back to Provider:
Printed name of VRS staff member making verification: / Date Verified:
Comment (if any):
DARS1616A Supported Employment Job Stability Justification Summary(10/17)Page 1 of 7