Vocational Rehabilitation Services
Customer Services Report:Orientation Mobility (O&M)Training
General Information
Provider’s name: / Service authorizationnumber:
Counselor’s / ILS-OIB Worker’s name: / Caseload number:
Customer’s name:
Customer street address:
Total training hours approved at assessment:
Total training hours provided to date:
Training hours provided this month:
Training hours requested for next service authorization:
Training
For each of the skills area trained, include the date of lesson, location, hours and a brief description of the lesson provided.
Basic Cane Skills area / Date of lesson / Location / Hours / Brief description
Open palm grip
Pencil grip
Walking in step
Touch and drag/two point touch
Stairs
Picking up dropped objects
Cane storage (including vehicles)
Seating
Entering and exiting doors
Introduction to sidewalk travel, driveways, and curb travel
Other, please specify
Basic cane skills training hours recommended: / Hours completed for the month.
Indoor Skills Area / Date of lesson / Location / Hours / Brief description
Straight line travel
Indoor numbering systems
Orientation
Problem solving
Stairs, escalators, and elevators
Locating objectives in unfamiliar places
Finding intersecting hallways
Soliciting information
Malls, grocery sores, small shops,
bus and train stations, etc.
Other, please specify
Indoor skills training hours recommended: / Hours completed for the month:
Outdoor Skills Area / Date of lesson / Location / Hours / Brief description
Address system
Sun cues
Traffic
Orientation
Problem solving
Soliciting information
Parking lots
Transportation systems such as buses, paratransit, and communicating with drivers
Other, please specify
Outdoor skills training hours recommended: / Hours completed for the month:
Intersection Skills area / Date of lesson / Location / Hours / Brief description
Approaching
Analyzing
Alignment
Lights
Nonlights
Actuated
Automatic
Crossing
Crowns
Challenging traffic (heavy turn lanes, light traffic at busy intersections, night time)
Correcting veering
Other, please specify
Intersection skills training hours recommended: / Hours completed for the month:
Extra Skills Area / Date of lesson / Location / Hours / Brief description
College campus
Rural travel
Airport, train, and bus terminals
Others as needed, please specify
Extra skills training hours recommended: / Hours completed for the month:
Additional Comments
Height of customer:
Height of rigid cane used for training:
Any additional comments or requests for support. Include any travel aids customer uses or may benefit from using:
Certification
I certify that all lessons not specified below were given non-visually and with a long rigid cane with metal tip.
Give exact dates of lessons that did not meet the standards below, and attach a copy of the written approval sent by the customer’s counselor/ILS-OIB worker.
Signatures
Orientation and Mobility SpecialistSignature (Required for all providers)
By signing below, I, the Orientation and Mobility Specialist, 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.
Orientation and Mobility Specialist typed name: / Orientation and Mobility Specialistsignature:
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?
- If yes, does the DARS 3490 approve the Director for the dates the services?
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.
- Enter the date a case note was made to document the return of invoice and required form(s)
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 number of training hours provided in each training area. / Yes / No
Verified that the detailed narrative of each skills area addressed during the reporting period and the training location for each lesson and a detailed explanation of anticipated training for the upcoming month is completed. / Yes / No
Verified that any deviation from assessment recommendations is explained. / Yes / No
Verified that a detailed narrative of cumulative progress is included if training is completed. / Yes / No
Verified that group training was provided to a maximum of three customers. / 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:
Original: VR counselor or ILS-OIB Worker
DARS2896 (10/17) Customer Services Report: Orientation & Mobility TrainingPage 1 of 5