Vocational Rehabilitation Services
Personal Social Adjustment Training (PSAT) and
Work Adjustment Training (WAT) Evaluation
General Information
Customername: / VRS Case ID:
Associated service authorization number:
Evaluation Completed for: / Personal Social Adjustment Training / WorkAdjustment Training
Training facilitated: In a group setting (maximum of six customers for each trainer)
In an individual setting (one trainer to one customer)
A combination of group and individual settings
If evaluation is facilitated in a group setting, record the VRS case IDs of all customers who participated in the group session(s).
1. / 2. / 3. / 4. / 5.
6. / 7. / 8. / 9. / 10.
Attendance
Instructions:
- For each week of the training, 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 training.
- If customer is absent from the training, 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 the customerparticipated in the Evaluation:
Areas to be Evaluated (based on referral)
Personal Social Adjustment Training
Acceptable work behaviors
Appropriate use of time and schedule management
Conflict resolution
Developing or restoring self-confidence
Developing socially acceptable behaviors
Disability management
Establishing basic etiquette
Other: / Personal appearance and grooming
Personal health and hygiene
Self-advocacy skills
Self-evaluation
Social relationships
Time/schedule management
Workplace interaction
Other:
Work Adjustment Training
Acceptance of supervision and directions
Daily living skills
Effective communication
Goal setting
Grooming, hygiene, work attire and/or dress code
Motivation
Problem solving
Other: / Self-regulation/reliance
Social skills
Understanding roles and responsibilities in the workplace
Work ethics
Work practices and productivity (including safety and speed)
Work tolerance
Other:
Other:
Evaluation Summary
Rate the customer’s performance:
Ability to learn / Excellent / Very Good / Good / Marginal / Poor
Accuracy of work / Excellent / Very Good / Good / Marginal / Poor
Accepts assistance / Excellent / Very Good / Good / Marginal / Poor
Adaptability / Excellent / Very Good / Good / Marginal / Poor
Appearance and hygiene / Excellent / Very Good / Good / Marginal / Poor
Attendance / Excellent / Very Good / Good / Marginal / Poor
Communication / Excellent / Very Good / Good / Marginal / Poor
Cooperativeness / Excellent / Very Good / Good / Marginal / Poor
Initiative / Excellent / Very Good / Good / Marginal / Poor
Motivation / Excellent / Very Good / Good / Marginal / Poor
Safety practices / Excellent / Very Good / Good / Marginal / Poor
Timeliness / Excellent / Very Good / Good / Marginal / Poor
Describe the customer’s ability and willingness to perform skills and tasks for each area identified in the referralincluding all problematic issues or concerns that emerge.Address all items identified in the referral.
Describe accommodations, compensatory techniques, and special training needs required by the customer.
Evaluations Results: No training recommended Training recommended
When training is recommended, the DARS3137B, VAT Specialized Training Plan completed and attached.
Additional comments, if any:
Signatures
Customer Signature
By signing below, I, the customer or authorized representative, agree with the information recorded within the report above. If you are not satisfied, do not sign. Contact your VR counselor.
Customer’s signature:
X / Date:
Customer’s legally authorized representative’s signature, if any:
X / Date:
Personal Social Adjustment Trainer and/or Work Adjustment Trainer Signature (Required for all providers)
By signing below, I, the Personal Social Adjustment Trainer and/or Work Adjustment Trainer, certify that:
- the above dates, times, and services are accurate;
- I personally facilitated theevaluation;
- all Outcomes Require for Payment as described in the TWC VR Standards for Provider and Service Authorization(s) were met;
- I personally documented the services and information described above on this form;
- the customer’s and/or customer’s legally authorized representative’s signature on this form was obtained on the date stated in the date field of the form;
- I handwrote my signature and the date below; and
- I maintain the staff qualifications required for a Personal Social Adjustment Trainer and/or Work Adjustment Trainer as described in the TWC VR Standards for Providers or Service Authorization .
Personal Social Adjustment Trainer typed name: / Personal Social Adjustment Trainer signature:
X / Date:
Work Adjustment Trainer typed name: / Work Adjustment Trainersignature:
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:
Verification of Qualifications
The UNTWISE website verifies that the director listed above is
NOT Credentialed Credentialed as a CRP Director
- If the Director, 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, 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:______
Printed name of VRS staff member making verifications: / Date verified:
VRS 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 that the form indicates that the training was provided in a group or individual setting and if a group setting a ratio of 1 Vocational Adjustment Trainer to no more than 6customers was maintained / Yes / No
Verified that the necessary accommodations, compensatory techniques, and special needs were provided and documented on the form by the vocational adjustment trainer as required for the customer’s successful engagement in the curriculum / Yes / No
Verified that the Personal Social Adjustment Trainer and/or Work Adjustment Trainer provided all supplies and resources necessary for the customer to participate in the training through signature on form or by VR staff member contact with customer / Yes / No
Verify that the DARS3137B, Personal Social Adjustment and/or Work Adjustment Training Plan is attached when the evaluation recommends training. / Yes / No
Verified the customer’s satisfaction with the training through signature on the form and/or by VR staff member contact with customer / 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:
Report: Approved Sent back to provider
Comment (if any):
Printed name of VR staff member making verification: / Date Verified:
DARS3137A (10/17) Personal Social Adjustment Training (PSAT) and Work Adjustment Training (WAT) EvaluationPage 1 of 6