Vocational Rehabilitation Services
Project SEARCH Placement Report
Instructions
- Write narrative summaries in paragraph form in clear, descriptive English leaving no fields blank. Enter N/A, if not applicable (i.e. a service not addressed or provided);
- Submit the invoice for payment the day after the Customer achieves a benchmark (i.e. the sixth day, the 46th day, and the 91st day).
- Complete the form electronically (on the computer), making certain all questions and all applicable standards have been met before submitting by fax, encrypted email, or mailing with an invoice for payment.
Benchmark Achieved
Instructions:check one
Form completed for:
Benchmark A - 5th day completed on the job
Benchmark B-45th day completed on the job
Benchmark C -90th day completed on the job
Other:
Customer’sIdentification Information
Customer name: / VRSCase ID:
Service authorization (SA) number:
Customer’s Employment Information
Enter the most recent placement information, below.
Employer’s Information
Original placement: / New placement:
Company name:
Street address (include suite number, if any):
City: / State: / ZIP code:
Main phone number:() / Supervisor phone number: ()
Customer’s supervisor’s name:
Supervisor’s job title: / Supervisor’s email address:
Estimated number of staff members employed by the business:
In the spaces below, check the best methods and times to contact the Customer’s supervisor:
Phone
Monday–Friday
Weekends / Morning
Noon to 5 p.m.
After 5 p.m.
Other:
Employment verification source (if other than supervisor):
Has the Customer been placed multiple times? / Yes No
If yes, complete information below:
Enter the dates of employment for previous placements.
First placement: / Start date: (month/day/year) / End date: (month/day/year)
Second placement: / Start date: (month/day/year) / End date: (month/day/year)
Customer Employee Information
Customer’s job title: / First day of paid employment (first day worked):
(month/day/year)
Average total number of hours the Customer works weekly:
Hourly wage: / Weekly gross earnings:
The Customer is paid:Weekly Every two weeks Monthly Other:
Job Placement Site 1: / Start date:
(first day on the job): / End date:
(last day on the job): / Number of cumulative calendar days completed:
Job Placement Site 2: / Start date:
(first day on the job): / End date:
(last day on the job): / Number of cumulative calendar days completed:
Job Placement Site 3: / Start date:
(first day on the job): / End date:
(last day on the job): / Number of cumulative calendar days completed:
Total number of cumulative calendar days worked within one 8-week period:
Customer’s Position Description
List the Customer’s primary job responsibilities:
Employment Conditions
The job placement specialist has completed DARS3373 Project SEARCH Job Placement Services — Plan to record the achievement of the employment goal and record the employment conditions.The specialist has submitted the plan with DARS3374. / Yes / No
Comments (if any):
Summary of the Customer’s Employment
Describe how the customer has adjusted to his or her job placement, including any issues or concerns and how they were addressed by the provider, employer, and customer.
Record a summary of the customer’s performance related to the job’s essential and nonessential job responsibilities.
Soft Skills
Instructions: Use the scale below to rate the customer’s overall performance.
Descriptions
Excellent: Performance far exceeded expectations because of exceptionally high quality of work.
Very Good: Performance consistently exceeded expectations.
Good: Performance consistently met expectations, at times possibly exceeding expectations.
Marginal: Performance did not consistently meet expectations.
Poor: Performance was consistently below expectations. Significant improvement is needed.
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 any accommodations, compensatory techniques, and special training needs that were identified or established at the worksite.
Describe any training provided by the business.
Describe any training and other services provided to the Customer to help him or her gain or maintain employment.
Describe results from visits and any consultations made with the business:
Additional comments, if any:
Visits with the Customer
Record a summary of the visits with the Customer between placement and the 45th day of employment.
Date:
Summary of visit:
Date:
Summary of visit:
Date:
Summary of visit:
Date:
Summary of visit:
Date:
Summary of visit:
Date:
Summary of visit:
Additional comments: (date entries)
Signaturesat Benchmarks
Instructions: New original signatures must be added each time the form is submitted. Indicate below the reason the form is being submitted.
For: Benchmark A Reporting Period Benchmark B Reporting Period
Benchmark C Reporting Period Other, describe:
Customer Signature
By signing below, I, the customer or authorized representative, agree with theEmployment Conditions and Employment Goal 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:
Provider Qualifications
Type of Provider: / Traditional-bilateral contractor
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 BID
SLIPI N/A / RID/BID/SLIPI Number:
Proof Attached / Yes No N/A
Other: / Number: Proof Attached / Yes No N/A
Job Placement Specialist Signature (Required for all providers)
By signing below, I, the Job Placement Specialist, certify that:
- the above dates, times, and services are accurate;
- 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 Job Placement Specialist as described in the TWC VR Standards for Providers or Service Authorization .
Job Placement Specialist typed name: / Job Placement 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:
VRS Use Only
Date Form Submitted by Provider:
Date Form Received by TWS-VRS Office:
Verification of Qualifications
The UNT website verifies that the director listed above is
NOT Credentialed Credentialed as a CRP Director
The UNT website or supporting documentation verifies the Job Placement Specialist listed above is
NOT Credentialed
Credentialed as a Job Placement Specialist
Maintains BEI, RID, SLPI required for Premium
Endorsed in Other Specialization, Specify
- If the Director or Job Placement 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 the Director and/or Job Placement Specialist for the dates of service?
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.
- 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 that the customer’s current employment and employer information is described on form / Yes / No
Verification the employment is in an integrated employment setting / Yes / No
Verification the customer worked 5 day prior to achievement of Benchmark A or worked 45 days for achievement of Benchmark B or worked 90 days for achievement of Benchmark C / Yes / No
Verification customer achieved 100% of non-negotiable employment conditions and at least 50% of the negotiable employment conditions at achievement of each benchmark / Yes / No
Verification customer achieved one of the six-digit SOCs listed with the employment goal / Yes / No
Verification at the original or any additional job placements, Job Placement Specialist assisted the customer in securing the job placement (training, job leads, etc.) / NA Yes / No
Verified that the necessary accommodations, compensatory techniques, and special needs were provided and documented on the form by the Job Placement Specialist / 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 to the provider with the 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:
DARS3374 (10/17)Project SEARCH Placement Report Page 1 of 7