Department of Assistive and Rehabilitative Services Work Experience Report  




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Department of Assistive and Rehabilitative Services

Work Experience Report  

Follow the instructions below when completing this form.  

  • Complete the form electronically (on the computer), answering all questions.

  • Complete one form for each staff person working with the consumer.  

  • The work experience specialist will record an answer to each question as it relates to the services provided.

  • Write narrative summaries in paragraph form in clear, descriptive English indicating how and when you collected the information in the narrative summaries.  

  • Review the form carefully and leave no blanks. Enter “N/A” if not applicable.

  • Make certain that all standards have been met before submitting this form with an invoice for payment.

  • Obtain signatures and submit. Signature must be obtained at each submission.

Note: The provider collects the information and completes this form except those sections indicated for “DARS use only.”  

This form is completed at Placement and at completion of each monthly Work Experience Report.  



Form Completed For:  

   Work experience—volunteer

   Work experience—internship

   Work experience—temporary paid work

Start date of services included in report:      

End date of services included in report:      

Work experience report completed for:    Placement    Monthly report    Other:      

Consumer Identification Information  

Consumer’s name:

     


Consumer Case ID:      

Consumer’s date of birth:      

Service authorization (SA) number:      

Consumer’s Work Experience Information  

Company name:     

Street address (include suite number, if any):

     


City:      

State:      

ZIP code:      

Main phone number: (   )      

Supervisor’s phone number: (   ).     

Consumer’s supervisor’s name:      

Supervisor’s job title:      

Supervisor’s email address:      

In the spaces below, enter X to select the best methods and times to contact the supervisor:  

   Phone

   Email

   Monday–Friday

   Weekends

   Morning

   Noon to 5 p.m.

   After 5 p.m.

   Other:      

Start date of the Work Experience:      

Projected end date of the Work Experience:      

Consumer’s Work Experience Job Title:

     


Average total number of hours the consumer will be at the Work Experience weekly:      

Earnings, if any (hourly wage, stipend, etc.):    None    Yes. Describe:      

Describe any accommodations, compensatory techniques, and special training needs identified or established at the Work Experience Site.

     


Is Work Experience Training and/or Coaching recommended and requested from DARS?
   Yes    No

If yes, on what should the training focus?

     


Summary of Work Experience Visits and Contact  

Instructions:

Summarize each visit or contact. The entries below should include all visits and contacts made with respect to securing and monitoring the consumer during the work experience.  



Date:      

Summary of visit or contact:

     


Date:      

Summary of visit or contact:

     


Date:      

Summary of visit or contact:

     


Date:      

Summary of visit or contact:

     


Date:      

Summary of visit or contact:

     


Date:      

Summary of visit or contact:

     


Date:      

Summary of visit or contact:

     


Date:      

Summary of visit or contact:

     


Date:      

Summary of visit or contact:

     


Date:      

Summary of visit or contact:

     


Work Experience Hours Completed by the Consumer  

Instructions:

For each week of the Work Experience, record the Sunday–Saturday of the week as the date, record the number of hours the consumer participated in the Work Experiences each day of the week, and total the hours worked for the week.  

At the completion of each report, total the hours the consumer participated for all weeks of the month and adjust the record comments as appropriate.  


Week

Date:

(Sun.–Sat.)



Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Total hours

1

     

     

     

     

     

     

     

     

     

2

     

     

     

     

     

     

     

     

     

3

     

     

     

     

     

     

     

     

     

4

     

     

     

     

     

     

     

     

     

5

     

     

     

     

     

     

     

     

     

Total hours for month

     

Comments, if any:

     


Consumer’s Performance-Evaluation of Soft Skills  

Instructions: The provider rates the consumer on the following criteria.  

Soft Skill

Excellent:
meets expectations

Fair:
meets expectations most of the time

Poor:
does not meet expectations

Not applicable:
not addressed

Ability to learn

  

  

  

  

Accuracy and quality of work

  

  

  

  

Accepts supervision

  

  

  

  

Adaptability

  

  

  

  

Admits mistakes

  

  

  

  

Appearance, dress, and hygiene

  

  

  

  

Asks for help and clarification as needed

  

  

  

  

Attendance

  

  

  

  

Communication

  

  

  

  

Cooperativeness

  

  

  

  

Co-worker relations

  

  

  

  

Dependability

  

  

  

  

Handles stress

  

  

  

  

Initiative

  

  

  

  

Listens and pays attention

  

  

  

  

Motivation

  

  

  

  

Maintains eye contact

  

  

  

  

Quantity of work

  

  

  

  

Refrains from unnecessary social interactions

  

  

  

  

Respects the rights and privacy of others

  

  

  

  

Safety practices

  

  

  

  

Service to customers

  

  

  

  

Timeliness and deadline achievement

  

  

  

  

Soft skills overall rating:

  

  

  




Additional comments on soft skills, if any:
     

Consumer’s Performance-Evaluation of Hard Skills  

Instructions: The provider rates the consumer on the following:  

Hard skills
Add hard skills, job skill tasks, and responsibilities of the Work Experience.

Excellent
meets expectations

Fair
meets expectations most of the time

Poor
does not meet expectations

Not applicable
not addressed

     

  

  

  

  

     

  

  

  

  

     

  

  

  

  

     

  

  

  

  

     

  

  

  

  

     

  

  

  

  

     

  

  

  

  

     

  

  

  

  

     

  

  

  

  

     

  

  

  

  

Hard skills overall rating:

  

  

  

  

Additional comments on hard skills, if any:
     

Summary of Consumer’s Work Experience  

Describe how the consumer has adjusted to his or her work experience including any problematic issues or concerns that emerged and how they were addressed.

     


Record a summary of the consumer’s performance related to the work experience’s essential and non-essential job responsibilities related to the position.

     


Did the consumer receive any Work Experience Training or Coaching?    Yes    No

If Yes, record a summary of the training.

     


Describe any consultations made at the Work Experience Site.

     


Additional Information  

Is the DARS1636, Work Experience Training/Coaching Report, attached?

   Yes

   No

Additional comments, if any:

     


Signatures at Placement and at Completion of Session  

Signatures for:    Placement    Monthly report    Other      

By signing below, I, the consumer, agree with the information recorded within the Work Experience Report above. If you are not satisfied, do not sign. Contact your DARS counselor.  

Consumer’s signature:

X      _________________________________

Date:

     ________

Consumer’s legally authorized representative’s signature, if any:

X      _________________________________

Date:

     ________

I, the worksite specialist, certify that:

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

  • I personally completed the Work Experience Report collecting information about the consumer through interviews with the Work Experience Site employees and supervisors and/or through observations of the consumer at the Work Experience Site.

  • I documented the services and information described above in the DARS1635;  

  • 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 handwrote my signature and the date below; and  

  • I maintain credentials required for a work experience specialist as described in the Standards for Providers and/or service authorization.

Type of credential or license(s)

In text box, describe level and type of credential or license(s).  



Number

DARS ONLY—Verified

UNT credential:      

     

  Yes   No    N/A Initials:      

Other:      

     

  Yes   No    N/A Initials:      

Work Experience Specialist:

Print or type name:

     

Date DARS1633 submitted:

Signature:

     ______________________________

     _____________

DARS Use Only—Verification of CRP’s Staff Credentials  

UNT website verifies that the CRPs staff person listed above is

   Credentialed   Not credentialed in Job Placement



If the work experience specialist is not credentialed, is an approved DARS3490, Temporary Waiver of CRP Credentials, attached to the invoice?

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



  Yes   No

  Yes   No



Printed name of DARS staff member making verification:      

Date verified:      

If unable to verify the credentials, complete the following:

  • Date a copy of the submitted invoice and report was returned to the CRP with written notification that CRP staff person did not meet one of the credential criteria required.

Date:

     

  • Date a case note was entered to document the return of invoice and required forms.

Date:

     

DARS Use Only—DARS Approval of the Report  

Verified that the Report is accurately completed per form instructions, the Standards for Providers, and the SA.

  Yes   No

Verified that the appropriate service(s) was provided as stated in the Standards for Providers and the SA.

  Yes    No

For Work Experience Placement only, was the DARS1634 also submitted?

  Yes    No

For Work Experience Placement only, did the provider provide initial assistance, training and support as needed by the consumer for the first week of the Work Experience?

  Yes    No

For Work Experience Placement only, was a minimum of one face-to-face meeting with consumer, work experience site supervisor, and provider held?

  Yes    No

For Work Experience Monitoring only, were visits and contacts with the consumer and work experience site staff members held and documented? (A monthly face-to-face visit is required; weekly check-ins are required.)

  Yes    No

Verified that appropriate rate was invoiced (Placement versus Monitoring and/or Nontraditional).

  Yes    No

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

  • Send a copy of the submitted invoice and the report to the CRP with written notification that the placement did not meet the requirements as described in the Standards for Providers and/or the SA.  

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 DARS staff member making verification:

     _______________________________

Date:

     

DARS Approval of the DARS1635:  

Reviewed:   

Approved:   

Sent back to provider:   

Counselor’s initials:      

Date:      

Comments:

     





DARS1635 (05/15) A+ Work Experience Report Page of



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