DSHS Form 11-097 "Service Delivery Outcome Report" - Washington

What Is DSHS Form 11-097?

This is a legal form that was released by the Washington State Department of Social and Health Services - a government authority operating within Washington. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2020;
  • The latest edition provided by the Washington State Department of Social and Health Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of DSHS Form 11-097 by clicking the link below or browse more documents and templates provided by the Washington State Department of Social and Health Services.

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Download DSHS Form 11-097 "Service Delivery Outcome Report" - Washington

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DIVISION OF VOCATIONAL REHABILITATION (DVR)
INDEPENDENT LIVING SERVICES (IL)
AFP NUMBER
Service Delivery Outcome Report
DVR CUSTOMER
SOCIAL SECURITY NUMBER (LAST FOUR DIGITS)
XXX-XX-
IL CONTRACTOR’S NAME
IL REPRESENTATIVE
DVR COUNSELOR
RATE
TOTAL COST
$
Hourly
Flat
IL SERVICE CATEGORY
IL Work Related Systems Access
IL Comprehensive Evaluation
IL Skills Training
IL Partial Evaluation
PRE-ETS (PRE-EMPLOYMENT TRANSITION SERVICES) IL SERVICE CATEGORY
Pre-ETS: IL Self-advocacy / Peer Mentoring
TIME LINES (OVERALL PLAN)
Monthly Update
From:
To:
Dates of this Reporting Period: From:
To:
REPORT
This document is only for reporting purposes. Invoices must be created in a separate document and submitted with this
Service Delivery Outcome Report.
I certify (or declare) under penalty of perjury under the laws of the State of Washington that the foregoing is true and
correct. (Revised Code of Washington 5.50.050)
IL REPRESENTATIVE’S SIGNATURE
DATE
Page 1 of 1
SERVICE DELIVERY OUTCOME REPORT
DSHS 11-097 (REV. 11/2021)
DIVISION OF VOCATIONAL REHABILITATION (DVR)
INDEPENDENT LIVING SERVICES (IL)
AFP NUMBER
Service Delivery Outcome Report
DVR CUSTOMER
SOCIAL SECURITY NUMBER (LAST FOUR DIGITS)
XXX-XX-
IL CONTRACTOR’S NAME
IL REPRESENTATIVE
DVR COUNSELOR
RATE
TOTAL COST
$
Hourly
Flat
IL SERVICE CATEGORY
IL Work Related Systems Access
IL Comprehensive Evaluation
IL Skills Training
IL Partial Evaluation
PRE-ETS (PRE-EMPLOYMENT TRANSITION SERVICES) IL SERVICE CATEGORY
Pre-ETS: IL Self-advocacy / Peer Mentoring
TIME LINES (OVERALL PLAN)
Monthly Update
From:
To:
Dates of this Reporting Period: From:
To:
REPORT
This document is only for reporting purposes. Invoices must be created in a separate document and submitted with this
Service Delivery Outcome Report.
I certify (or declare) under penalty of perjury under the laws of the State of Washington that the foregoing is true and
correct. (Revised Code of Washington 5.50.050)
IL REPRESENTATIVE’S SIGNATURE
DATE
Page 1 of 1
SERVICE DELIVERY OUTCOME REPORT
DSHS 11-097 (REV. 11/2021)