Vocational Rehabilitation Services
Environmental Work Assessment (EWA)
Part C—Signature Page
General Instructions
This form is completed by the provider that conducted the assessment. The following four documents are required for payment:
· A completed DARS1877 EWA: Part A (Summary)
· A completed DARS1877 EWA: Part B (Results)
· A completed DARS1877 EWA: Part C (Signature Page)
· A completed DARS1878 EWA: Time Log
Customer Information
Customer’s name: / Case ID:
Signatures
I, the provider certify that:
· I personally conducted the environmental work assessment;
· I assessed the customer in three work environments;
· I reviewed Part A and Part B in person with the counselor, customer, and/or guardian. If there was an exception to meeting in person, the counselor approved this;
· I completed and turned in DARS1877 Part A, Part B, and Part C;
· I completed and turned in DARS1878;
· I handwrote my signature and the date below;
· I maintain the credentials required for the autism specialization as described in the Division for Rehabilitation Services Standards for Providers manual; and
· I have provided my University of North Texas (UNT) credential number and my UNT autism credential number below.
UNT credential number: / UNT autism credential number:
Provider’s name:
Provider’s signature:
X
VRS Use Only—Verification of Autism Specialization Credential
I verified on the UNT WISE website that the provider maintains the required autism specialization.
The provider is Credentialed Not credentialed
If the provider is not credentialed as required, is an approved DARS3490, Temporary Waiver of CRP Credentials, attached to the invoice? / Yes / No / N/A
If yes, does the DARS3490 waive the missing credential(s) for the service dates of the environmental work assessment? / Yes / No / N/A
If you are unable to verify the credentials or the approved DARS3490, complete the following:
· Enter the date that a copy of the submitted invoice and report was returned to the CRP with written notification that CRP staff person did not meet the credential criteria required or submit an approved DARS3490 waiving the required credential. / Date:
· Enter the date of the case note documenting 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 Report
Four documents are required for payment. Enter an X for each document that has been submitted.
If a document has not been submitted, leave the square unmarked.
Completed DARS1877 EWA, Part A (Summary)
Completed DARS1877 EWA, Part B (Results)
Completed DARS1877 EWA, Part C (Signature Page)
Completed DARS1878 EWA, Time Log
EWA: Part A
Sections 1-10 of EWA Part A are completed. / Yes / No
EWA: Part B
The customer self-assessment score sheet is completed. / Yes / No
The three environmental score sheets are completed. / Yes / No
The summary and comparison of environments are completed. / Yes / No
The best fit and recommendations are completed. / Yes / No
EWA Time Log
I verified that the time log is completed and has the required signatures. / Yes / No
I verified that no more than 8 indirect hours were spent on this assessment. / Yes / No
I verified that no fewer than 12 direct hours were spent on this assessment. / Yes / No
I verified that no fewer than 20 total hours were spent on this assessment. / Yes / No
I verified that three environments were assessed. / Yes / No
Payment
I verified that the appropriate fee of $990 was invoiced. / Yes / No
If any question above is answered “No,” complete the following:
· Send a copy of the submitted invoice and the report to the provider with written notification that the service delivery or report 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:
Report: Approved Sent back to provider
Comments:
Printed name of VRS staff member making verification: / Date verified:
DARS1877C (10/17) Environmental Work Assessment (EWA) Part C—Signature Page Page 1 of 3