/ Texas Workforce Commission
Vocational Rehabilitation Services
Diabetes Education
Post Training Assessment
Instructions
  • Review previous visit.
  • Summarize customer abilities in behaviors and use of adaptive equipment.
  • Record customer statements and diabetes educator observations and comments.
  • As appropriate, you may use the following abbreviations: NA for “not applicable”, ND for “not disclosed by customer”, or NE for “not evaluated”.

General Information
Customer name: / TWS-VRS Case ID:
Counselor name: / Service authorization number:
Previous Visit
Date of previous visit:
What was the behavioral change goal from the previous visit?
Did the customer accomplish the behavioral change goal? Describe successes and barriers to change.
How did you evaluate the behavioral change goal (return demonstration, verbal feedback, etc.)?
What does the customer recall from the previous visit?
Was there anything that was difficult for the customer to implement?
Summarize customer’s abilities in the following behaviors:
Vocational Rehabilitation
Healthy Eating
Being Active
Monitoring
Taking Medications
Healthy Coping
Problem Solving
Reducing Risk
Is the customer independent with the following adaptive aids? If not, please provide a reason the customer is not independent and the plan of action.
Adaptive Aid / Yes / No / N/A / Comment
Count-a-Dose
Insulin Pen
Magniguide
Blood Glucose Meter
BodyWeight Scale
Blood Pressure Meter
Thermometer
Other adaptive equipment purchased (Describe in comment)
Customer Statements
What changes in your lifestyle have you made while completing the diabetes program?
What changes will be difficult to maintain?
Do you have the information you need to manage your diabetes at work? (VR customers only)
Final Observations, Comments, and Recommendations
Does the customer have the skills to manage his or her health during intensive rehabilitation training programs (minitrainings, CCRC, etc.)? / Yes No / Comment:
Observations, comments, and recommendations not covered previously:
Start time of visit: / End time of visit:
Postassessment date: / Total hours for postassessment:
Signatures
Diabetes EducatorSignature (Required for all providers)
By signing below, I, the Diabetes Educator, 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.

Diabetes Educator typed name: / Diabetes Educatorsignature:
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:
The section below for 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?
/ Yes No N/A
  • If yes, does the DARS 3490 approve the Director for the dates the services?
/ Yes No N/A
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.
Date: .
  • Enter the date a case note was made to document the return of invoice and required form(s)
Date: .
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 form was completed in its entirety / Yes / No
Verified that this individual session was held for one hour / Yes / No
Verified that the form was submitted to VRS within 35 days of completion / Yes / No
Verified that the form summarizes the customer abilities in behaviors and use of adaptive equipment. / 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:

DARS2900 (9/27/2016) Diabetes Self-Management Education Post-Training AssessmentPage 1 of 5