/ Texas Workforce Commission
Vocational Rehabilitation Services
Vocational AssessmentReport
Followthe instructions below when completing this form.
  • Complete the form electronically (on the computer) 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.
  • Make certain that all standards are met before submitting this form with an invoice for payment.

Provider Information
Provider: / Service authorization Number:
Return Report To
Counselor Name: / Address:
City: / State: / ZIP:
Customer Information
Customer Name: / Case ID:
Customer Address: / Date of Birth:
City: / State: / ZIP Code:
Telephone:()
Attendance
Instructions:
  • For each week of the evaluation, enter the date (mm/dd/yy) of Monday through Sunday in the date column.
  • For each day of the week, record the number of hour(s) the Customer participated in the evaluation.
  • If Customer is absent from the evaluation, record an “A” for the day missed.
  • Notify the counselor immediately when the Customer is absent.
  • Total the number of hours that the Customer attended the evaluation.

Week / Date
(Mon-Sun) / Monday / Tuesday / Wednesday / Thursday / Friday / Saturday / Sunday
1
2
3
4
5
6
Total number of hours Customerparticipated in the Evaluation:
Questions
Date(s) of Evaluation:
Reason for Referral:
Background Information(including visual impairment; other medical conditions; academic, psychological, and work history; vocational training; and social and emotional information):
Tests Administered:
Interpretations of Tests Results (including a summary of strengths and limitations):
Customer’s Vocational Interests(including addressing compatibility of interests to measured skills and abilities):
Behavioral Observations:
Recommendations
(in narrative format address the following areas)
Response to the specific referral questions:
Customer’s optimal level of employment potential and job readiness:
Specific occupations for the customer to consider and explore:
Job-related accommodations or adaptations, if needed:
Any additional training or education needed for employment:
Other evaluations, if needed (for example, psychological, medical, assistive technology, etc.):
Consideration for supported employment services, if appropriate:
Independent living needs, accommodations, and adaptations:
Other vocational rehabilitation needs:
Signatures
Vocational Evaluator Signature (Required for all providers)
By signing below, I, the Vocational Evaluator, certify that:
  • the above dates, times, and services are accurate;
  • I remained onsite to supervise all services and vocational evaluator aides maintaining the required ratios as stated in the Standards for Providers;
  • a minimum of six hours of assessment was provided each day;
  • I personally conducted the assessment and prepared this form;
  • allOutcomes Require for Payment, as described in the TWC VR Standards for Provider and Service Authorization(s) were met;
  • I maintain the staff qualifications required for a Vocational Evaluator as described in the TWC VR Standards for Providers or Service Authorization.

Vocational Evaluator typed name: / Vocational Evaluator 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:
The UNT website verifies that the director listed above is
NOT Credentialed Credentialed as a CRP Director
  • If the Director is not credentialed, is an approved DARS 3490, Temporary Waiver of CRP Credentials, attached to the invoice?
/ Yes No N/A
  • If yes, does the DARS 3490 approve the Director for the dates the 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 Standards for Providers, and/or the SA / Yes / No
Verified that the appropriate service(s) was provided as stated in the Standards for Providers and/or the SA / Yes / No
identify appropriate and inappropriate behaviors using existing records, personal observations, and conversations with the VR counselor, customer, family members, and others / Yes / No
Verified that the form indicates results of evaluator findings and observations specified in the service description / Yes / No
Verified that the form indicates descriptions of the customer’s appropriate and inappropriate behaviorsusing existing records, personal observations, and conversations with the VR counselor, customer, family members, and others / Yes / No
Verified that the form indicates potential for competitive integrated employment or reasons competitive integrated employment is not appropriate, when applicable / Yes / No
Verified that the form indicates job recommendations related to the current job market using the Standard Occupational Classification codes for the customer's geographic area / Yes / No
Verified that the form indicates specific training options that match the customer’s capabilities / Yes / No
Verified that the form indicates specific job modifications and/or accommodations / Yes / No
When requested on the DARS1836, Vocational Assessment Referral or service authorization verify a feedback session to review the customer’s vocational interests, strengths, challenges, and recommendations with the customer, customer’s representative, if any and VR counselor was be completed / 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:

  • 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:

DARS1837 (10/17)Vocational Assessment ReportPage 1 of 4