/ Texas Workforce Commission
Vocational Rehabilitation Services
Project SEARCHExtended Services, Retention Services,
and Long-Term Support ServicesSummary Report
General Instructions
The contractor records all of the extended services, retention services, and long-term support services to be provided, managed, or arranged by long-term support organizations or natural sources of support to ensure the Customer is able to stay employed once VRS closes the Customer’s case. These services and sources of support include both on-site and off-site monitoring,as requested by the Customer orthe Customer’s legal representative to ensure that the Customer maintains job stability.
Description of the Extended Service, Retention Service, and/or Long-term Support Need / Frequency of Service and/or Need / Name, Title/Relationship and Contact Information of Person/Business providing the Service/Support Need / Service/Need is documented in the Customer’s Plan of Care of any Long-Term Support Organization or with Employer as an Accommodation / VRS Staff- Verification Service/Need has been Set-up
(record staff initials)
1. / Yes No Not Applicable / Yes No
2. / Yes No Not Applicable / Yes No
3. / Yes No Not Applicable / Yes No
4. / Yes No Not Applicable / Yes No
5. / Yes No Not Applicable / Yes No
6. / Yes No Not Applicable / Yes No
7. / Yes No Not Applicable / Yes No
8. / Yes No Not Applicable / Yes No
9. / Yes No Not Applicable / Yes No
10. / Yes No Not Applicable / Yes No
11. / Yes No Not Applicable / Yes No
12. / Yes No Not Applicable / Yes No
Comments, if any:
Signatures
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
By signing below, I, the Job Placement Specialist, certify that:
  • I documented the information on the form based on the customer’s needs at this time as identified by their circle of support;
  • 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 Job Placement Specialist, as described in Standards for Providers and/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:
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:______
  • Enter the date a case note was made to document the return of invoice and required form(s)
Date: ______
Date Form Submitted by Provider:
Date Form Received by TWS-VRS Office:
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 VRS staff member making verifications: / Date verified:

DARS3375 (10/17)Project SEARCH Extended Services, Retention Services, and Long-Term Support Services Summary ReportPage 1 of 4