/ Texas Workforce Commission
Vocational Rehabilitation Services
Supported EmploymentService Closure 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 the customer’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 that all quality criteria have been met.
  • Submit invoice for payment no sooner than the day after achievement of the benchmark 6.
Note: The provider collects the information and completes this form except for the section indicated for “VRS Verify.”
Indicate which benchmark is being documented.
Benchmark 6: Closure Other, 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 146 cumulative calendar days. / Yes / No
Date “Job Stability” was achieved as defined in the standards for providers. / //
Date the customer achieved “Case Closure Status” as defined in the standardsfor providers. / //
Employment was verified through(select as appropriate):
Employer contact Customer contact Directly observing the customer at work
Other. Describe:

Signatures

Customer Signature
I, the customer (or legally authorized representative), am satisfied and certify the dates, times, and services are accurate.If you are not satisfied, do not sign and contact your VR counselor.
Yes, I, the customer am happy and satisfied with my job. No
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 (select all that apply):
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 director is not credentialed, is an approved DARS3490, Temporary Waiver of CRP Credentials, attached to the invoice?
/ Yes No N/A
  • If yes, does the DARS 3490 approve services with the correct service dates?
/ Yes No N/A
VRS Use Only—Verification of CRP’s Director UNT Credentials
The UNT website verifies that the CRPs 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? / Yes No N/A
  • If yes, does the DARS3490 approve services with the correct service dates?
/ Yes No N/A
If unable to verify the credentials, complete the following:
  • Enter the date a copy of the submitted invoice and DARS1616B was returned to the CRP with written notification that CRP staff person did not meet one of the credential criteria required.
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 verification: / Date verified:
VRS Use Only—VRS Approval of the DARS 1616B
Instructions:
Review the DARS1616B. 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.
If the Autism Employment Premium has been authorized, were the supported employment specialist’s credentials for Autism Employment Premium verified? / Yes No N/A
Verified that the DARS1616B is accurately completed per instructions on form and the standards for providers. / Yes No
Verified that the customer has been employed at least 90 days from date of Stability. / Yes No
Verified that the DARS1616B 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
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.
/ Date:
  • Record a case note to document the return of invoice and required form(s)
/ Date Recorded:
Report:Approved Sent back to provider / Date Sent Back to Provider:
Printed name of VRS staff member making verification: / Date Verified:
Comment (if any):

DARS1616B Supported Employment Service Closure (10/17) A+ Page 1 of 5