Sample Form DR381 "Supported Employment - Job Placement Parameters" - California

What Is Form DR381?

This is a legal form that was released by the California Department of Rehabilitation - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 1, 2008;
  • The latest edition provided by the California Department of Rehabilitation;
  • 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 Form DR381 by clicking the link below or browse more documents and templates provided by the California Department of Rehabilitation.

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Download Sample Form DR381 "Supported Employment - Job Placement Parameters" - California

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STATE OF CALIFORNIA
DEPARTMENT OF REHABILITATION
SUPPORTED EMPLOYMENT - JOB PLACEMENT PARAMETERS
DR381 (Rev. 02/08)
SE Service Provider Name & Address:
Consumer:
Date:
Independent Opportunity Support Center
John Jacob Jingleheimer-
12/30/2008
12345 Independence Boulevard
Scmidt
Funkytown, CA 91233
DOR Counselor:
DOR District:
Alexandra Hamilton
Greater Los Angeles
Attn: La Fonda Maka-Jobs, Job Developer
SEP#:
DOR Counselor Fax:
Individual
Group
999
(213) 736-3949
Consumer Job Choices:
First:
Welder Helper
Second: Construction Helper
Third:
Landscape Laborer
Work Week Goal (Hours/Week):
40
Mon:
Tues:
Wed:
Thurs:
Fri:
Sat:
Sun:
7 am -
7 am -
7 am -
7 am -
7 am -
9 am -
-
Days/Hours Available:
5 pm
5 pm
5 pm
5 pm
5 pm
12 pm
(example 9am-10pm)
Preferred Location:
West Funkytown
Location Restrictions: within walking distance of Metro or bus
Mode of Travel:
public transit and bicycle, occaisonal rides from B&C in bad weather
Travel Restrictions:
Metro, bus
Comments:
availability depends on various location/bus schedule, prefers to work w/ men
FUNCTIONAL LIMITATIONS: Check all that apply
Mobility
Communication (i.e. hearing, seeing, speaking)
Self Care
Work Skills
Work Tolerance
Cognitive Restrictions (i.e. literacy)
Physical Restrictions
Medications/Side Effects
Environmental Considerations (i.e. Heights, Machinery, Direct Sunlight, Heat, Cold, Dust, etc.)
Other (i.e. conditions of probation) Explain: red-green color blind
Specifics / Recommended Accommodation(s)
MO: Unable to drive. COM: Needs to be asked yes/no questions. SEL: Hygiene and grooming can be
rd
problemmatic. COG: Reads at 3
grade level. Requires repetition for memory retention.
DOR Counselor Certification: I have discussed the above job placement parameters with the consumer and the SE
Service Provider. The conditions are consistent with the IPE and the consumer’s choices in Supported Employment.
DOR Counselor Signature:
Email Address:
Phone Number:
Date Signed:
ahamilto@dor.ca.gov
(213) 736-3904
12/30/2008
Distribution:
Consumer
SE Service Provider
DOR Record of Services
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.
STATE OF CALIFORNIA
DEPARTMENT OF REHABILITATION
SUPPORTED EMPLOYMENT - JOB PLACEMENT PARAMETERS
DR381 (Rev. 02/08)
SE Service Provider Name & Address:
Consumer:
Date:
Independent Opportunity Support Center
John Jacob Jingleheimer-
12/30/2008
12345 Independence Boulevard
Scmidt
Funkytown, CA 91233
DOR Counselor:
DOR District:
Alexandra Hamilton
Greater Los Angeles
Attn: La Fonda Maka-Jobs, Job Developer
SEP#:
DOR Counselor Fax:
Individual
Group
999
(213) 736-3949
Consumer Job Choices:
First:
Welder Helper
Second: Construction Helper
Third:
Landscape Laborer
Work Week Goal (Hours/Week):
40
Mon:
Tues:
Wed:
Thurs:
Fri:
Sat:
Sun:
7 am -
7 am -
7 am -
7 am -
7 am -
9 am -
-
Days/Hours Available:
5 pm
5 pm
5 pm
5 pm
5 pm
12 pm
(example 9am-10pm)
Preferred Location:
West Funkytown
Location Restrictions: within walking distance of Metro or bus
Mode of Travel:
public transit and bicycle, occaisonal rides from B&C in bad weather
Travel Restrictions:
Metro, bus
Comments:
availability depends on various location/bus schedule, prefers to work w/ men
FUNCTIONAL LIMITATIONS: Check all that apply
Mobility
Communication (i.e. hearing, seeing, speaking)
Self Care
Work Skills
Work Tolerance
Cognitive Restrictions (i.e. literacy)
Physical Restrictions
Medications/Side Effects
Environmental Considerations (i.e. Heights, Machinery, Direct Sunlight, Heat, Cold, Dust, etc.)
Other (i.e. conditions of probation) Explain: red-green color blind
Specifics / Recommended Accommodation(s)
MO: Unable to drive. COM: Needs to be asked yes/no questions. SEL: Hygiene and grooming can be
rd
problemmatic. COG: Reads at 3
grade level. Requires repetition for memory retention.
DOR Counselor Certification: I have discussed the above job placement parameters with the consumer and the SE
Service Provider. The conditions are consistent with the IPE and the consumer’s choices in Supported Employment.
DOR Counselor Signature:
Email Address:
Phone Number:
Date Signed:
ahamilto@dor.ca.gov
(213) 736-3904
12/30/2008
Distribution:
Consumer
SE Service Provider
DOR Record of Services
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.