Vocational Rehabilitation Services
Situational Assessment and Work Sample Report
General Instructions
Followthe instructions below to complete 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 inked 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: / Fax:
Address: / Email:
City: / State: / ZIP:
CustomerInformation
Customer Name: / Case ID:
Customer Address: / Date of Birth:
City: / State: / ZIP code:
Primary contact number: () / Email:
Assessment & Work Sample Components
Situational Assessments
A situational assessment is conducted at three or more competitive integrated work sites within a business or industry setting in the community. The vocational evaluator must observe the customer for a minimum of two hours per competitive integrated work site. After the customer participates in the situational assessment, record responses to the questions below.
Situational Assessment Number 1
Time spent:
Business name:
Business location:
Describe the setting.
Describe what you saw the customer do and list any skills he or she demonstrated:
Summary of the customer’s functional abilities observed during the assessment.
Summary of the customer’s functional limitations, challenges, and barriers observed during assessment.
Instructions for the table below:
Record your observations for each item listed below as demonstrated by customer during the assessment.
Category / Unlikely to change behavior in work setting / Possibility to change behavior in work setting / Behavior in work setting needs improvement / Behavior in work setting is acceptable / Behavior in work setting is good
Appropriate personal relations with supervisor
Open and clear communication with supervisor on work site
Comfortable interacting with supervisor
Anxious interacting with supervisor
Benefits from instruction from supervisor
Cooperates with others on work tasks
Understands and follows through on instructions
Productivity is consistent
Punctuality
Grooming/Dress
Motivation to perform tasks
Maintains attention to tasks
Recognizes difference between work, school, home, and recreation
Appropriate relations with co-workers
Works well with co-workers
Accepts unpleasant tasks
Organizes work
Initiates work independently
Adapts to change in the work setting
Shows ability to learn
Frustration tolerance
Aware of workplace rules and safety rules and precautions
Inappropriate work behaviors
Additional comments:
Situational Assessment Number 2
Time spent:
Business name:
Business location:
Describe the setting.
Describe what you saw the customer do and list any skills he or she demonstrated:
Summary of the customer’s functional abilities observed during the assessment.
Summary of the customer’s functional limitations, challenges, and barriers observed during assessment.
Category / Unlikely to change behavior in work setting / Possibility to change behavior in work setting / Behavior in work setting needs improvement / Behavior in work setting is acceptable / Behavior in work setting is good
Appropriate personal relations with supervisor
Open and clear communication with supervisor on work site
Comfortable interacting with supervisor
Anxious interacting with supervisor
Benefits from instruction from supervisor
Cooperates with others on work tasks
Understands and follows through on instructions
Productivity is consistent
Punctuality
Grooming/Dress
Motivation to perform tasks
Maintains attention to tasks
Recognizes difference between work, school, home, and recreation
Appropriate relations with co-workers
Works well with co-workers
Accepts unpleasant tasks
Organizes work
Initiates work independently
Adapts to change in the work setting
Shows ability to learn
Frustration tolerance
Aware of workplace rules and safety rules and precautions
Inappropriate work behaviors
Appropriate personal relations with supervisor
Additional comments:
Situational Assessment Number 3
Time spent:
Business name:
Business location:
Describe the setting.
Describe what you saw the customer do and list any skills he or she demonstrated:
Summary of the customer’s functional abilities observed during the assessment.
Summary of the customer’s functional limitations, challenges, and barriers observed during assessment.
Category / Unlikely to change behavior in work setting / Possibility to change behavior in work setting / Behavior in work setting needs improvement / Behavior in work setting is acceptable / Behavior in work setting is good
Appropriate personal relations with supervisor
Open and clear communication with supervisor on work site
Comfortable interacting with supervisor
Anxious interacting with supervisor
Benefits from instruction from supervisor
Cooperates with others on work tasks
Understands and follows through on instructions
Productivity is consistent
Punctuality
Grooming/Dress
Motivation to perform tasks
Maintains attention to tasks
Recognizes difference between work, school, home, and recreation
Appropriate relations with co-workers
Works well with co-workers
Accepts unpleasant tasks
Organizes work
Initiates work independently
Adapts to change in the work setting
Shows ability to learn
Frustration tolerance
Aware of workplace rules and safety rules and precautions
Inappropriate work behaviors
Appropriate personal relations with supervisor
Additional comments:
Work Samples
A minimum of four Work Samples that were not completed in the vocational assessment must be completed. Work samples provide a close simulation of an actual industrial task, business operation, or component of an occupational area. After the customer participates in the work sample, record responses to the questions below.
Work Sample Number 1
Time spent:
Business or Industry Type:
Testing Environment:
Describe what you saw the customer do and list any skills he or she demonstrated:
Category / Strongly Disagree / Disagree / Neutral / Agree / Strongly Agree
Accepted instruction regarding the work sample
Ability to follow 2 step directions
Ability to follow multi-step directions
Learned without extra instruction
Learned with extra instruction
Demonstrated Aptitude for skill
Demonstrated Aptitude for task
Performed task without assistance
Performed task with assistance
Demonstrated interest in task
Demonstrated dislike of task
Work product met expectations
Production time met expectations
Task would be appropriate job task
Summary of the customer’s functional limitations, challenges, and barriers observed during work sample.
Additional comments:
Work Sample Number 2
Time spent:
Business or Industry Type:
Testing Environment:
Describe what you saw the customer do and list any skills he or she demonstrated:
Category / Strongly Disagree / Disagree / Neutral / Agree / Strongly Agree
Accepted instruction regarding the work sample
Ability to follow 2 step directions
Ability to follow multi-step directions
Learned without extra instruction
Learned with extra instruction
Demonstrated Aptitude for skill
Demonstrated Aptitude for task
Performed task without assistance
Performed task with assistance
Demonstrated interest in task
Demonstrated dislike of task
Work product met expectations
Production time met expectations
Task would be appropriate job task
Summary of the customer’s functional limitations, challenges, and barriers observed during work sample.
Additional comments:
Work Sample Number 3
Time spent:
Business or Industry Type:
Testing Environment:
Description of tasks and skills performed.
Category / Strongly Disagree / Disagree / Neutral / Agree / Strongly Agree
Accepted instruction regarding the work sample
Ability to follow 2 step directions
Ability to follow multi-step directions
Learned without extra instruction
Learned with extra instruction
Demonstrated Aptitude for skill
Demonstrated Aptitude for task
Performed task without assistance
Performed task with assistance
Demonstrated interest in task
Demonstrated dislike of task
Work product met expectations
Production time met expectations
Task would be appropriate job task
Summary of the customer’s functional limitations, challenges, and barriers observed during work sample.
Additional comments:
Work Sample Number 4
Time spent:
Business or Industry Type:
Testing Environment:
Description of tasks and skills performed.
Category / Strongly Disagree / Disagree / Neutral / Agree / Strongly Agree
Accepted instruction regarding the work sample
Ability to follow 2 step directions
Ability to follow multi-step directions
Learned without extra instruction
Learned with extra instruction
Demonstrated Aptitude for skill
Demonstrated Aptitude for task
Performed task without assistance
Performed task with assistance
Demonstrated interest in task
Demonstrated dislike of task
Work product met expectations
Production time met expectations
Task would be appropriate job task
Summary of the customer’s functional limitations, challenges, and barriers observed during work sample.
Additional Comments:
Summary of Situational Assessments & Work Samples
Based on the information you have gathered, describe the type of jobs and/or employment goal that would be the best employment setting for the customer.
Based on the information you have gathered, describe the environment and work culture that would be the best employment setting for the customer.
Based on the information you have gathered, what should be avoided to identify the best employment setting for the customer?
Describe such supports as social, communication, learning, environmental, assistive technology, or other supports potentially necessary to promote customer success in competitive integrated employment.
Based on the situational assessments and work samples, would the customer most likely succeed in competitive, integrated employment?
If you do not recommend competitive, integrated employment for the customer explain why.
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;;
- I provided a minimum of six hours of assessment 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) are 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 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 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?
- If yes, does the DARS3490 approve services with the correct service dates?
If unable to verify the credentials or the approved DARS3490, complete the following:
- Enter the date a copy of the submitted invoice and DARS1838 was returned to the CRP with written notification that CRP director did not meet the credential criteria required or submit an approved DARS3490 waiving the required credential.
- Enter the date a case note was entered to document the return of invoice and required form(s)
Printed name of VRS staff member making verification: / Date verified:
Instructions:
Review the DARS1838. 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 1838
Verified the Director Credentials have been verified. / Yes / No
Verified the appropriate fee(s) were invoiced / Yes / No
Verified that the DARS1838 is accurately completed per form instructions on form and in accordance with the Standards for Providers. / Yes / No
Verified that the information in all sections of the form are unique and individualized for the customer. / Yes / No
Verified that the supported employment specialist collected information through customer observations held at multiple occasions and locations. / Yes / No
Verified that a total of three Situational Assessments were completed in different work settings. / Yes / No
Verified that all signatures are present on the form. / Yes / No
Verified that the DARS1838 was submitted with invoice with appropriate dates of service. / Yes / No
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) Date recorded:
Report:Approved Sent back to provider
Printed name of VRS staff member making verification: / Date Verified
Comment (if any):
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