Department of Assistive and Rehabilitative Services Supported Employment Support Summary  




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Department of Assistive and Rehabilitative Services

Supported Employment Support Summary  




General Instructions  




Refer to the DRS Standards for Providers, Chapter 8: Standards for Employment Services, 8.7 Job Skills Training (Job Coaching) and DBS Standards Manual for Consumer Services Contract Providers, Chapter 5: Services, 5.12 Standards for Supported Employment Services and quality criteria for additional details.  




The placement must continue to meet all nonnegotiable employment conditions, 50 percent or more of negotiable employment conditions, and at least one targeted job task listed in the SESP—Part 1.  

If the consumer is placed in any new subsequent positions or jobs, a new Supported Employment Support Summary (SESP)—Part 2 form must be completed, signed by all parties, and submitted with the DARS1615.  

Follow the instructions below when completing this form:


  • Information on the form must be submitted electronically and be accurate and complete.

  • The supported employment specialist (SES) will record an answer to all questions. If a question or section does not apply, enter “Not Applicable” or N/A and explain why.  

  • Write narrative summaries in paragraph form in clear, descriptive English.

  • Indicate how and when you collected the information in the narrative summaries. For example, “the supported employment specialist collected the information through discussion with the consumer’s supervisor on March 5, 2014,” or “the supported employment specialist observed the consumer performing (skill or task) at the job site on March 5, 2014.”  

  • Before submitting with an invoice for payment, review the document to ensure that all questions have been answered, the standards for providers outcomes have been met and that all quality criteria have been met.  

  • Submit invoice for payment no sooner than the day after achievement of the benchmark (for example, the 6th day, the 29th day, the 56th day)

Note: The provider collects the information and completes this form except the section indicated for “DARS Use Only.”  




Enter X below to indicate which benchmark this form is being used for.




   Benchmark 3: four-week job maintenance    Benchmark 4: eight-week job maintenance




Identification Information  




Consumer’s name:

     


DARS consumer number:

     





Employment Information  




Consumer’s job title:

     


First day worked in current placement:

  /  /     (month/day/year)






Average number of hours the consumer works weekly:      




Original (first) placement:

   Yes

   No




New placement or position (must submit a new DARS1614 with this DARS1615):

   Yes

   No




Complete the information below only if the consumer is placed in a new job.  




Updated SESP—Part 2 submitted for new placement?

   Yes

   No




First placement: Start date:   /  /     (month/day/year)

End date:   /  /     (month/day/year)






Second placement: Start date:   /  /    

End date:   /  /    






Service Delivery Information Support Summary  




The consumer has worked at least 28 cumulative calendar days.

   Yes

   No




The consumer has worked at least 56 cumulative calendar days.

   Yes

   No




Employment was verified through:

   Employer contact    Consumer contact    Directly observing the consumer at work

   Other: Describe:      





Briefly describe the consumer’s essential and episodic job duties and the consumer’s ability to perform each job duty:




     




Describe how the consumer has adjusted to his or her job, including any problematic issues or concerns that emerged and how they were addressed:




     




Describe evidence of how the consumer is meeting the expectations and demands of the employer, including the level of satisfaction the employer has with the consumer’s job performance:




     




Describe evidence to support the consumer’s and, if applicable, the consumer’s legal representative’s (family member or other) satisfaction with the job and the work environment:




     




Describe what types, methods, and strategies were used in training the consumer and the effectiveness of the training provided:

     

Explain the amount and extent of supports identified in the SESP Part 2 that were provided during this period including the type, frequency, methods, and strategies that were used:

     

What new support or accommodation needs, if any, were identified during this period, and how were they addressed?

     

Briefly describe the amount and type of training and other services you provided to the consumer to help him or her maintain employment:

     


Additional comments:

     


Signatures  

Consumer Signature

I, the consumer (or legally authorized representative), am satisfied and certify that the dates, times, and services are accurate.   If you are not satisfied, do not sign. Contact your DARS counselor.

Consumer’s signature:

X      

Date:      

Signature of consumer’s representative or legal guardian (if applicable):

X      

Date:      

Supported employment specialist signature

I, the supported employment specialist certify that  

  • the above dates, times, and services are accurate;  

  • I personally provided all services or supervised the credential job skills trainer who provided the services recorded within the DARS1615, Supported Employment Support Summary;  

  • I documented the services and information described above in the report;

  • the consumer’s and/or consumer’s legally authorized representative’s signature on this form was gained on the date stated in the date field of the form;  

  • I hand wrote my signature and dated this form; and

  • I maintain credentials required for a supported employment specialist as described in the standards for providers.  

First and last name of supported employment specialist:

     


UNT credential number:

     


Signature of the supported employment specialist who completed the report:

X      

Date:

     


Job skills trainer signature    Not applicable

I, the job skills trainer, certify that  

  • the above dates, times, and services are accurate;  

  • I was supervised by the supported employment specialist when I personally provided services as recorded within the DARS1615;  

  • I hand wrote my signature and dated and;

  • I maintain credentials required for a job skills trainer as described in the standards for providers.

Job skills trainer’s first and last name:

     


UNT credential number:

     


Job skills trainer’s signature:

X      

Date:

     


DARS Use Only—Verification of UNT Credentials  

Credentials have been verified on the DARS1613.

   Yes    No

Job coach and/or job skills trainer verification    Not applicable

UNT website verifies that the CRPs staff person listed above is:

   NOT Credentialed    Credentialed in Job Placement    Credentialed in Autism Specialization

If the job coach/job skills trainer is not credentialed, is an approved DARS3490, Temporary Waiver of CRP Credentials, attached to the invoice? (For DRS only. DBS does not use DARS3490.)

If yes, does the DARS3490 approve services with correct service dates?



   Yes    No

   Yes    No



Printed name of DARS staff member making the verification:

     

Date verified:      

If unable to verify the credentials or the approved DARS3490, complete the following:  

  • The date a copy of the submitted invoice and DARS1615 were returned to the CRP with written notification that CRP staff person did not meet the credential criteria required or submit an approved DARS3490 waiving the required credential. Date:      

  • The date a case note was entered to document the return of invoice and required form(s).

Date:      

DARS Use Only—Verification of Job Coach and/or Job Skill Trainer  

Deaf Services Premium Approval    Not applicable

Purchase Order issued for Deaf Service Premium?   Yes    No. If no, skip to next section. (A copy of the certification should be attached to the form and invoice.)

If Yes, Board for Evaluation of Interpreters (BEI) certification    Credentialed    Not credentialed

Registry of Interpreters for the Deaf (RID) certification    Credentialed    Not credentialed

SLPI rating of intermediate plus    Credentialed    Not credentialed


Printed name of DARS staff member

making verification:



     

Date verified:

     

If unable to verify the credentials, complete the following:  

  • The date a copy of the submitted invoice and DARS 1613 were returned to the CRP with written notification that the CRP staff person did not meet one of the credential criteria required.

Date:      

  • The date a case note was entered to document the return of invoice and required form(s)

Date:      

DARS Use Only—DARS Approval of the DARS1615  

Supported Employment Credentials have been verified on the DARS1613.

   Yes    No

If the Deaf Employment Premium Services has been authorized, were the supported employment specialist’s or job coach and/or job skills trainer’s credentials for Deaf Employment Premium verified?

   Yes    No

   N/A


Verified that the DARS1615 is accurately completed per form instructions on form and the standards for providers.

   Yes    No

Verified that the consumer has been employed at least 28 or 56 days from date of placement.

   Yes    No

Verified that the DARS 1615 identifies the consumer’s performance and the consumer’s abilities related to essential job tasks, training needs, and supports to be provided to ensure the consumer’s success.

   Yes    No

Verified that extended services and/or long-term supports are being addressed and put into place by the provider.

   Yes    No

Verified that consumer, parent and/or guardian, and employer continue to be satisfied with the placement.

   Yes    No

Verified that wages are at or above minimum wage but not less than the customary or usual wage paid by the employer for the same or similar work performed by people who do not have disabilities.

   Yes    No

Verified that the consumer is working in a “competitive work setting” as defined in the standards for providers.

   Yes    No

Verified that the consumer is working in an “integrated work setting” as defined in the standards for providers.

   Yes    No

Consumer is satisfied with the job placement via signature on form or by consumer contact.

   Yes    No

Verified that all additional requirements of the placement noted in the “special comments” of the service authorization were met.

   Yes    No

If any question above is answered “No,” complete the following:  

  • Send a copy of the submitted invoice, DARS1615 and DARS 1613 returned to the CRP with written notification that the placement did not meet the requirements as described in the standards for providers. Date sent:      

  • Record a case note to document the return of invoice and required form(s)

Date recorded:      

DARS1615:

   Approved

   Sent back to provider


Printed name of DARS staff member making verification:

     


Date:

     





DARS1615 (12/15) A+ Supported Employment Support Summary Page of


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