/ Texas Workforce Commission
Vocational Rehabilitation Services
Bundled Job Placement Services
Plan-Part B and Status Report
General Instructions
Instructions: Follow the instructions below when completing this form and its associated procedures:
  • DARS1845A, Bundled Job Placement Services Placement Plan-Part A must be completed prior to the development of the following Placement Plan sections:Employment Conditions and Employment Goal.
  • Before any servicesare provided,the Placement Plan-Part B will be completedelectronically (on the computer) by VRS staff at the Planning Meeting with all signatures gained at the end of the meeting. VRS staff memberwill place the original signed paper copyin the VRS case file.
  • At the conclusion of the meeting, VRS staff will provide to the provider: a printed paper copy of the signed Placement Plan-Part B and a Microsoft Office Word file of the form so that the form can be used by the provider for each benchmark reporting period. The form will contain previously recorded information for each benchmark submitted. Each time the form is completed new signatures must be obtained prior to submitting to VRS.
  • If the employment goal changes or non-negotiable conditions become negotiable,a new updated Placement Plan must be completed by holding a Job Placement Planning Meeting before the customerbegins employment. VRS staff members and the customer will make the final decisions related to the employment goal and non-negotiable conditions.

Demographic Information
Basic Bundled Job Placement Services / Enhanced Bundled Job Placement Services
Customername: / VRS case ID:
Service authorization (SA)number:
Placement Plan-Employment Conditions
Instructions:
  • VRS staff will record all Employment Conditions in measurable terms and indicate if the Employment Conditions are “negotiable” or “non-negotiable.”Address support needs and any mandatory commitments that must be planned around for the customer to maintain a long-term Job Placement. Record “N/A” if an Employment Condition criterion does not apply to the customer.
  • Job placement specialist will check the box under the appropriate benchmark to indicate whetherthe Employment Condition was achieved. If the Employment Condition was not achieved, the box will not be checked.For the 5th day, the customer must have worked 5 days on the job, not cumulative calendar days, for the 45th and 90th day the customer must have been employed 45 or 90 days.

Employment Conditions / Negotiable / Non-negotiable / Achieved at:
5th day / 45th day / 90th day

1. Minimum and maximum number of hours to work per week:

Minimum and maximum

/

N/A

2. Minimum and maximum hours per shift:

Minimum and maximum

/ N/A

3. Weekday hours available (Record the times the customer is available to work each day.):

Monday:
Tuesday:
Wednesday:
Thursday:
Friday:

4. Weekend hours available (Record the times the customer is available to work each day.):

Saturday:
Sunday:

5. Earnings cannot be less than (choose one):

/month, or /week, or /hour

6. Distance and time willing to travel to and from work:

7. Transportation method(s):

8. Mandatory commitment(s) that must be accommodated:
(for example, child and/or elder care, religious observances, entitlements, waivers, criminal charges or convictions, and parole):
N/A
N/A
N/A
9. List job site accommodation(s) and other support needs.
(for example, physical restrictions, supervision, training needs, or adaptive equipment):
10. Other:
11. Other:
Placement Plan - Employment Goal(s)
Instructions:
  • VRS staff will record the System Occupational Code (SOC) for each goal using the full, 6-digit SOCCluster-SOC-Codes.
  • The SOC code must match the job duties of the job obtained.
  • The measurable goal section should include a detailed description of what job responsibilities, skills and work duties the customer wants to perform as it relates to the SOC.
  • Job Placement Specialist records the achievement of the Employment Goal at each Benchmark timeframe.One goal must be achieved.

6-Digit SOC Code(s) / Measurable employment goal(s) / Achieved at:
5th day / 45th day / 90th day
Does the customer’s employment goal support the need for a Resume? Yes No
Premiums
Instructions:
  • The VR Counselor will determine if a customer’s case is eligible for a premium at planning meeting.
  • Service Authorization(s) for premium(s)must be issued with Benchmark A service authorization.
  • The Job Placement Specialist identifies premiums achieved after completion of Benchmark C.

Eligible Premium(s) / Achieved Premium(s) after completion of Benchmark C
Autism Service Premium / Yes No / Autism Service Premium / Yes No
Criminal Background Premium / Yes No / Criminal Background Premium / Yes No
Deaf Service Premium / Yes No / Deaf Service Premium
If yes, attach proof of certification / Yes No
Professional Placement Premium / Yes No / Professional Placement Premium
If yes, attach proof of degree / Yes No
Wage Premium / Yes No / Wage Premium
If yes, attachdetailed pay statement / Yes No
Other: / Yes No / Other: / Yes No
Job Placement Information
Instructions: Record the start date and end dates, if applicable, for placements gained and lost.
First placementstart date:
Has customer required multiple placements? Yes No
If yes, enter the applicable start and end dates below:
End date of first placement: / Start date of second placement:
End date of second placement: / Start date of third placement:
Employer Information
Instructions: Update for each position held by the customer.
Completed for: First Placement Second Placement Third Placement
Company name:
Street address (include suite number, if any):
City: / State: / ZIP code:
Main phone number: () / Company website:
Supervisor’s (or contact person’s) name:
Supervisor’s (or contact person’s) title:
Supervisor’s direct phone number:()
Supervisor’s email address:
Select the best method and time to contact the customer’s supervisor:
Phone / Email / In person / Day and time:
Customer Employment Information
Instructions: Update for each position held by the customer.
Completed for: First Placement Second Placement Third Placement
Customer’s job title:
Description of job duties and responsibilities:
How does the employer classify the position (check all that apply):
Permanent Temp-to-hire Seasonal Full-time Part-time As needed (PRN)
Contract Employee that will receive an IRS1099 Other: Describe:
Work Schedule: Record the start time, end time of work day and total hours worked daily below.
Weekday: / Monday / Tuesday / Wednesday / Thursday / Friday / Saturday / Sunday
StartTime:
EndTime:
Total Hours:
Average hours customer works weekly:
Do you expect the customer’s hours to change weekly? Yes No
Hourly wage: / Gross weekly earnings:
The customer is paid: / Weekly / Bi-Weekly (every two weeks)
Monthly (one time each month) / Bi-Monthly (twice each month)
Other:

Service Delivery Information at Placement—5th day

Record the first 5 days the customer worked performing work duties and hours worked each day.
Day 1 / Date: / Hours Worked: / Comments:
Day 2 / Date: / Hours Worked: / Comments:
Day 3 / Date: / Hours Worked: / Comments:
Day 4 / Date: / Hours Worked: / Comments:
Day 5 / Date: / Hours Worked: / Comments:
Employment schedule and work hours was verified through:
Employer contact Customer contact Pay Stub Observing the customer at work
Other: Describe:
Describe the role(s) of the Job Placement Specialist in assisting the customer with obtaining and maintaining the job.
Describe any steps taken to customize the position for the customer to meet the needs of the customer and the business. (for example, blending job descriptions)
Describe all accommodations, compensatory techniques, and special training needs identified or established to increase the customer’s performance in the work setting: (environmental changes, assistive technology devices, or work process)
Describe any consultations made with the business.
Service Delivery Information at Placement, 45th day- Benchmark B
The customer has been employed and worked at least 45 days Yes No N/A
Employment was verified through:
Employer contact Observing the customer at work Customer contact
Other: Describe:
Describe all accommodations, compensatory techniques, and special training needs identified or established at the worksite:
Describe how the customer has adjusted to the job. Include all 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 responsibilities:
Describe any consultations made with the business:
Service Delivery Information at Placement, 90th day- Benchmark C
The customer has been employed and worked at least 90 days Yes No N/A
Employment was verified through:
Employer contact Observing the customer at work Customer contact
Other: Describe:
Describe all accommodations, compensatory techniques, and special training needs identified or established at the worksite:
Describe how the customer has adjusted to the job. Include all 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 responsibilities:
Describe any consultations made with the business:
Visits with the Customer
Instructions:
Record a brief summary of the visits with thecustomer.Must have two visits for each reporting period.
Date:
Summary of visit:
Date:
Summary of visit:
Date:
Summary of visit:
Date:
Summary of visit:
Date:
Summary of visit:
Date:
Summary of visit:
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
Additional comments, if any:
Signatures
Instructions: New original signatures must be added each time the form is submitted. Indicate below the reason the form is being submitted.
For: Original Planning Meeting Updated Planning Meeting: Date:
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 recorded on thisPlacement Plan Report- Part 2 during the Job Placement Planning Meeting and 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:
VR Counselor Signature(only required at the Placement Planning Meeting(s))
By signing below, I, the customer’s Vocational Rehabilitation Counselor agree with the Employment Conditions, Employment Goaland Premium service recorded on this Placement Plan Report- Part 2 during the Job Placement Planning Meeting.
VR Counselor’s signature:
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 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:
For Placement Planning Meeting(s)
  • I am in agreement with the Employment Conditions, Employment Goal and Premium service recorded on this Placement Plan Report- Part 2 during the Job Placement Planning Meeting.
For Benchmarks Status Reports submitted at completion of Benchmarks A, B and C
  • the above dates, times, and services are accurate;
  • all Outcomes Required 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?
/ Yes No N/A
  • If yes, does the DARS 3490 approve the Director and/or Job Placement Specialist for the dates of service?
/ Yes No N/A
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:
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
Verified the employment is in an integrated employment setting / Yes / No
Verified the customer worked 5 day prior to achievement of Benchmark A or worked 45days for achievement of Benchmark B or worked 90 days for achievement of Benchmark C / Yes / No
Verified customer achieved 100% of non-negotiable employment conditions and at least 50% of the negotiable employment conditions at achievement of each benchmark / Yes / No
Verified customer achieved one of the six-digit SOCs listed as a measurable employment goal / Yes / No
Verified 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 customer’s satisfaction with the training through signature on the form and/or by VR staff member contact with customer / Yes / No
Verified 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:

DARS1845B (10/17) Bundled Job Placement Services Benchmark Services Plan-Part B and Benchmark Status Report Page 1 of 9