/ Texas Workforce Commission
Vocational Rehabilitation Services
Assistive Technology Training Referral
Customer Information (required)
VR Counselor Name: / CaseloadNumber: / Office Number:
()
Trainer Name and Contractor Agency: / Date of Referral:
Customer’s Name: / Customer’s date of birth: / Customer’s Primary Language:
Customer’s street address: / City: / State: / ZIP Code:
Phone Number:
() / Alternate Contact Number (Mobile Number):
()
Best Day(s) to Contact (if known):
Customer’s Educational and/or Vocational Goal(s):

Visual Acuities (required)

Visual Diagnosis:
Visual Acuity: / O D (right eye): / O S (left eye): / Visual Fields:
Other Additional Information:

Customer’s Hardware and Software (required)

List the hardware the customer currently has:
List the software the customer currently has:

Keyboarding and Braille Speeds (required)

Typing Speed: / Braille Reading Speed:

Baseline Assessment (required)

Has a baseline assessment for this customer already been completed?Yes No
If yes, the previous baseline assessment, unless it is older than one year, must be attached to this referral. Was it attached? Comments:
If no, or the previous baseline assessment is older than one year, then a service authorization for a baseline assessment must be issued before training can begin.

Customer’s Preferred Training Location (if known)

Select the check box(s) below that apply
Customer’sown home/family home
Customer’s work site
Customer’s educational site (school) / Contractor’s facility
Community center
Other: Specify:

Projected Training Modules (required)

Check box(s) below that apply
Keyboarding Skills Training
Setting Up the Workstation
Operation System Features and Functions
Screen Readers
Word Processor / Scanning and Embossing
Notetakers
The Internet
Other, Specify:

Circumstances that May Impact Services (required)

Secondary Disability:
If secondary disability is deaf blindness, what is the customer’s primary form of communication?
Level of Education: / Known Health Issues/ Safety Concerns:
Additional Information:

Required Attachments

Assistive Technology Evaluation Report, if applicable
Baseline Assessment, if applicable
Signatures
Evaluator’s or Trainer’sSignature (Required for all providers)
By signing below, I, the evaluator or trainer, certify that:
  • the above dates, times, and services are accurate;
  • I personally provided all services and documented all information described on 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 the service provided as described in the TWC VR Standards for Providers or Service Authorization.

Evaluator’s or trainer’s typed name: / Evaluator’s or trainer’ssignature:
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 UNTWISE 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 and form 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 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
Verified the evaluator or trainer documented and/or addressed required typing speed at 30 wpm. / Yes / No
Verified the evaluator or trainer documented and/or addressed required braille speed at 50 wpm if applicable. / Yes / No
Verified the evaluator or trainer documented vision condition and acutities/field loss / Yes / No
Verified the evaluator or trainerattached all required documentation to this form. / Yes / No
Verified that the appropriate fee(s) was invoiced / Yes / No
If any question above is answered “No,” complete the following:
  • Send a copy of the submitted invoice and the report with the DARS3460 to the provider for written notification that 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:

Report: Approved Sent back to provider
Comment (if any):
Printed name of VR staff member making verification: / Date Verified:

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