State of California - Department of Rehabilitation

STATE OF CALIFORNIA DEPARTMENT OF REHABILITATION

SUPPORTED EMPLOYMENT - PROPOSED PLAN TO IMPROVE PERFORMANCE

DR384A (New 06/04) Attachment to DR384 Supported Employment - Monthly Job Coach Report

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STATE OF CALIFORNIA DEPARTMENT OF REHABILITATION

SUPPORTED EMPLOYMENT - MONTHLY JOB COACH REPORT

DR384 (New 06/04) / Report Month/Year:
Employer/Site Name & Address: / Consumer: / DOR Counselor:
SE Service Provider:
Solano Diversified Services / DOR District:
Mt. Diablo
Job Coach: / Job Coach Phone:
Job Title:
Day Maintainence / Individual
Group / Wage:
per hour / Start Date:

Work Schedule (indicate work hours; example: 9am-2pm):

Monday / Tuesday / Wednesday / Thursday / Friday / Saturday / Sunday
Total hours consumer worked / Total hours coached
On-site coaching / Job coach travel hours (IP only)
Off-site coaching (IP only) / Total hours billed
Percent of intervention (IP only) / (cannot exceed hours authorized)
Total hours authorized
IP only = Individual Placement Only / Date services authorized through

Check boxes for any areas of unsatisfactory performance

Work Habits Work Performance Interpersonal Skills

Attendance/Punctuality Understanding of Job Tasks Supervisor

Following Procedures Accuracy/Quality Co-workers

Cooperation Work Pace Customer/Public

Taking Initiative Focus/Concentration Job Coach

Grooming/Hygiene

Areas checked must be addressed in a proposed plan to improve performance

Check if plan is attached. (May use DR384A or provider’s equivalent report)

Other issues related to job performance/termination:
Consumer comments/view of progress:
Termination Date: / Form Completed By: / Phone:

DOR Use Only: Account Tech Initials Invoice Processed Date:

Other:

NOTICE: This is confidential information from the records of the California Department of Rehabilitation. State and federal law and departmental regulations prohibit you from making any further disclosure of this information without the informed, written consent of the person to whom this information pertains.

Consumer: / Job Coach: / DOR Counselor: / Report Month/Year:

Check the performance areas below that were indicated as unsatisfactory on the DR384. For each area checked, address the interventions proposed to improve performance including timeframes and recommendations for other services as required.

Work Habits

Attendance / Punctuality (Interventions & Timeframes):

Following Procedures (Interventions & Timeframes):

Cooperation (Interventions & Timeframes):

Taking Initiative (Interventions & Timeframes):

Grooming / Hygiene (Interventions & Timeframes):

Work Performance

Understanding of Job Tasks (Interventions & Timeframes):

Accuracy / Quality (Interventions & Timeframes):

Work Pace (Interventions & Timeframes):

Focus / Concentration (Interventions & Timeframes):

Interpersonal Skills

Supervisor (Interventions & Timeframes):

Co-workers (Interventions & Timeframes):

Customer / Public (Interventions & Timeframes):

Job Coach (Interventions & Timeframes):

NOTICE: This is confidential information from the records of the California Department of Rehabilitation. State and federal law and departmental regulations prohibit you from making any further disclosure of this information without the informed, written consent of the person to whom this information pertains.