Vocational Rehabilitation Services
Supported Employment Service Plan – 1
Extended Supports
Instructions:
- The Supported Employment Service Plan (SESP) Part 1 planning meeting is led by the customerwith assistance from the team in facilitating the planning meeting.
- VRS staff members complete the DARS1613A, DARS1613B, and DARS1613C during the SESP—Part 1 planning meeting.
- SESP—Part 1 all parts must be completed before any service can be provided.
- When a SESP—Part 1 needs to be updated for any reason, the updated SESP—Part 1 must be completed before any days are counted towards the achievement of a benchmark. Examples of when a SESP—Part 1 needs to be updated include:the Targeted Job Tasks change, or a non-negotiable Employment Condition become negotiable, or 100% of the non-negotiable Employment Condition and at least 50% of the negotiable Employment Conditions cannot be achieved with the placement. The VRS staff and the customer will make the final decisions related to changes to the SESP—Part 1 related to the Employment Conditions, Targeted Job Tasks, and Extended Service needs.
- All signatures for the DARS1613A will be collected at the conclusion of the planning meeting and initialed on 1613B & 1613C.
- All signatures for the DARS1613B, C, & D in the Signatures for Benchmark Status Reports Section will be collected at the completion of each benchmark.
- VRS staff members provide encrypted electronic copy (MSWord document – not the scanned version) of the completed SESP—Part 1(1613A, B, C, & D)form to the provider after the planning meeting. This is the form that the Supported Employment Specialist (SES)will update at the achievement of each benchmark.
- At Benchmarks 2–6, the SES updates the SESP—Part 1 to document the current status of Targeted Job Tasks, Employment Conditions,ExtendedServicesand Hours Worked by the Customer. As the form is submitted, the previous recorded information for each benchmarkshould remainon the form.Eligible Premiums and Indication of Achievement at 90 Days of Placement Section should be updated at Benchmark 6.New signatures must be gained at each benchmark.
- The SES submits the invoice the day after achievement of the benchmark (for example, the day after the completion of working for 5 days/shifts,29th day, 57th day)
Customer Identification
Customer name: / VRS Case ID: / Associated service authorization number:
Benchmark Information
Indicate at each submission one benchmark or reason the form is being completed:
Benchmark 1b Benchmark 2 Benchmark 3 Benchmark 4 Benchmark 5 Benchmark 6 Other(explain):
Extended Services
List any resources available to assist the customer with Extended Services needed to maintain long-term competitive employment.For example, other state agency programs such as CLASS, HCS or general funds or alternate funding resources such as grants,social security waivers or non-profits programs.
Instructions: Supported Employment Specialist must record all Extended Services (Long-Term Support Services) to be provided, managed, or arranged by Long-Term Support Organization(s) or “Natural Supports” to ensure that the customer is able to maintain employment once VRS closes thecase. These services and supports include both on-site and off-site monitoring, as requested by the customer or legal representative toensure that the customer maintains employment stability. This section must be addressed and updated at the planning meeting and at each benchmark. VRS will verify the Extended Service prior to a case being determined Job Stable.
Record the Benchmark the Extended Service Need was Identified / Describe the Extended Service Need Identified
(Examples: transportation, medication management, job coaching, reporting income to SSA) / Anticipated Frequency Extended Service
(Examples:
4 hours daily, 5 hours per week, ormonthly visit) / Source of Funding for Extended Service and Contact Information
(Examples CLASS, HCS, TxHmL, private pay, IRWE, PASS, donated or natural support) / Extended Service Documented with Funding Source
(Examples: CLASS-Implementation Plan, IRWE-Social Security Approved Plan, Employer-Accommodation Documented per Employer’s Policy, Natural Support- Not applicable) / VRS staff verification that service and/or need has been set up(record staff initials)
1b / 2 / 3 / 4 / 5 / 6
1. / Funding Source:
Name:
Title/Relationship:
Phone:
Email: / Yes No N/A
Date to Begin: / Yes
No
Initials:
Date:
2. / Funding Source:
Name:
Title/Relationship:
Phone:
Email: / Yes No N/A
Date to Begin: / Yes
No
Initials:
Date:
3. / Funding Source:
Name:
Title/Relationship:
Phone:
Email: / Yes No N/A
Date to Begin: / Yes
No
Initials:
Date:
4. / Funding Source:
Name:
Title/Relationship:
Phone:
Email: / Yes No N/A
Date to Begin: / Yes
No
Initials:
Date:
5. / Funding Source:
Name:
Title/Relationship:
Phone:
Email: / Yes No N/A
Date to Begin: / Yes
No
Initials:
Date:
Comments, if any:
MUST COMPLETE DARS1613A,B, & C FOR PLAN TO BE COMPLETE
Initials at time of Plan
By initialing in the appropriate space below, I am agreeing and certifying my agreement with the plan as developed on this date:
Customer’s Initials: / Customer Representative’s Initials:
VRS Counselor’s Initials: / Provider SES’s Initials:
Signatures at Benchmarks
Customer Signature
By signing below, I, the customer or the legally authorized representative (when applicable) understand, agree, and certify the job I havemeets 100% Non-negotiable and at least 50% negotiable conditions with at least one targeted job task.I am satisfied with these conditions, job tasks, and services.If I am not satisfied I will not sign the form and I will contact my VRS counselor.
Customer’s signature
X / Date:
Customer’s legally authorized representative’s signature, if any:
X / Date:
Provider Qualifications
Type of Provider: / Traditional-bilateral contractor / Transition Educator / Non-traditional
Traditional-bilateral contractor must complete the provider qualification section below. This section is not applicable to Transition Educator and Non-traditional providers.
Qualifications / Proof of Qualification / Verified by TWS-VRS
Specify UNTWISE Credential:
/ UNTWISE Credential Number: if no, DARS3490-Waiver Proof Attached / Yes No N/A
Specify UNTWISE Endorsement:
N/A / UNTWISE Endorsement Number: / Yes No N/A
Select: RID BEI
SLIPI N/A / RID/BEI/SLIPI Number:
Proof Attached / Yes No N/A
Other: / Number: Proof Attached / Yes No N/A
Supported Employment Specialist signature
By signing below, I, the provider, agree with the Employment Conditions, Job Tasks, Potential Employers and Business Types, and Extended Services stated on DARS 1613A,B, & C and have followed the plan when developing the job for the customer. I certify the jobmeets 100% Non-negotiable and 50%negotiable conditions with at least one targeted job task and by the customer’s signature above,the customer or legally authorized representative is satisfied with these conditions, job tasks, and services.
By signing below, I, the Supported Employment Specialist, additionally certify that:
- the above dates, times, and services are accurate;
- I personally provided services recorded on this form and associated invoice;
- I documented the information on the form for the customer represented 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, including the UNT WISE credential, required for a Supported Employment Specialist, as described in Standards for Providers and/or Service Authorization.
Supported Employment Specialist typed name: / Supported Employment Specialist 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 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:
Date Form Submitted by Provider:
Date Form Received by TWS-VRS Office:
VRS Use Only—Verification of CRP’s Staff UNT Credentials and Endorsements
The UNT website verifies that the CRPs staff person listed above is
NOT Credentialed Credentialed in Supported Employment
Endorsed in Autism Specialization Other (such as BEI, RID, SLPI)
Endorsed in Other Specialization Endorsed in Other Specialization
- If the supported employment specialist is not credentialed, is an approved DARS 3490, Temporary Waiver of CRP Credentials, attached to the invoice?
- If yes, does the DARS 3490 approve services with the correct service dates?
VRS Use Only—Verification of CRP Director’s UNT Credentials
The UNT website verifies that the CRPs director person listed above is
NOT Credentialed Credentialed as 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 services with the correct service dates?
Printed name of VRS staff member making verification: / Date verified:
If unable to verify the credentials, complete the following:
- Enter the date a copy of the submitted invoice and DARS 1612 was returned to the CRP with written notification that CRP staff person or director 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)
Instructions:
Review the DARS1613 A, B, C, and/or D. 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 1613C
Verified the DARS1613C is accurately completed per form instructions and the standards for providers. Yes No
Verified that the DARS1613C was submitted with invoice with appropriate dates of service. Yes No
At Benchmark 1b and anytime the DARS1613B or C was updated, verified all signatures/initials on forms. Yes No N/A
At benchmarks 1b, 2, 3, 4, 5, and 6, verified that the Extended Services and Long-term Supports are documentedin the Extended Services section of the DARS1613C. / Yes No
At benchmark 5 and 6, the Extended Services section of the DARS1613C identifies all necessary Extended Services are in place and workingto ensure long-term success integrated competitive employment such as:
- Extended Service funded or provided through Long Term Supports and Services (LTSS), such as CLASS, TxHmL or HCShave an approved Plan of Care and approved funds and/or
- Extended Service not funded or provided through LTSS, have a community resource such as Social Security Incentives, non-profits, natural supports, or private pay arrangements made
At benchmark 5 and 6, the Extended Services section of the DARS1613C have all Extended Services providers been verified by VRSwith the VRS only section recording all Yeses. / Yes No
At Benchmark 6, were any of the following eligible Employment Premium Services authorized by a Service Authorization and invoiced requirements verified?
Autism Services Premium requirement met / Yes No N/A
Criminal Background Premium requirement met / Yes No N/A
Deaf Services Premium requirement met / Yes No N/A
Professional Placement Premium requirement met / Yes No N/A
Other Services Premium requirement met / Yes No N/A
Other Services Premium requirement met / Yes No N/A
Wage Premium requirement met / Yes No N/A
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)
Report: Approved Sent back to provider
Printed name of VRS staff member making verification: / Date Verified
Comment (if any):
DARS1613C Supported Employment Service Plan - 1 Extended Supports (10/17)Page 1 of 6