Form DR383 "Supported Employment (Se) - Job Placement Information" - California

What Is Form DR383?

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 January 1, 2017;
  • 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 fillable version of Form DR383 by clicking the link below or browse more documents and templates provided by the California Department of Rehabilitation.

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Download Form DR383 "Supported Employment (Se) - Job Placement Information" - California

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STATE OF CALIFORNIA
DEPARTMENT OF REHABILITATION
Date:
SUPPORTED EMPLOYMENT
-
JOB PLACEMENT INFORMATION
DR383 (Rev. 01/17)
SE Service Provider Name & Address:
Consumer:
UCI #:
DOR Counselor:
DOR District:
Employer/Work Site Name & Address:
Individual
Group,
DR297JC hereby requested.
Job Title:
Start Date:
Employer Phone Number:
Supervisor Name:
# Employees at Worksite:
Non-Disabled
Disabled
Wage:
per
Hours per Week:
Probation Period:
 Employer
Who is paying consumer?
SE Service Provider
Is this customary wage?
Yes
No
Benefits:
Medical
Vacation
Sick Leave
Are these customary benefits?
Yes
No
If not, is consumer expected to earn customary wage/benefits by case closure?
Yes
No
Not Applicable
Work Schedule (indicate work hours; example: 9am-2pm):
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
 Regional Center
 Other:
Transportation funded by:
DOR
Travel:
Mode of travel:
Number minutes one way:
Job Description:
Consistent w
Job Placement Parameters (see DR381)?
Yes
No
Consistent w
Functional Capacities (see DR381)?
Yes
No
 No
Accommodations Needed (not including job coaching)?
Yes
If Yes, describe:
Job Coaching Plan/Services Recommended: (must include job coach hours needed)
include reference to DR297JC
 Tools
 Adaptive Technology
Additional Needs:
Clothing
Benefits Counseling
 Other
Wage Reporting
Description (request DOR authorization, if needed):
SE Service Provider Signature:
Email Address:
Phone Number:
Date Signed:
Distribution:
DOR District Office (with Invoice)
DOR Counselor (via email or fax
)
Regional C
, see DR381
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
Date:
SUPPORTED EMPLOYMENT
-
JOB PLACEMENT INFORMATION
DR383 (Rev. 01/17)
SE Service Provider Name & Address:
Consumer:
UCI #:
DOR Counselor:
DOR District:
Employer/Work Site Name & Address:
Individual
Group,
DR297JC hereby requested.
Job Title:
Start Date:
Employer Phone Number:
Supervisor Name:
# Employees at Worksite:
Non-Disabled
Disabled
Wage:
per
Hours per Week:
Probation Period:
 Employer
Who is paying consumer?
SE Service Provider
Is this customary wage?
Yes
No
Benefits:
Medical
Vacation
Sick Leave
Are these customary benefits?
Yes
No
If not, is consumer expected to earn customary wage/benefits by case closure?
Yes
No
Not Applicable
Work Schedule (indicate work hours; example: 9am-2pm):
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
 Regional Center
 Other:
Transportation funded by:
DOR
Travel:
Mode of travel:
Number minutes one way:
Job Description:
Consistent w
Job Placement Parameters (see DR381)?
Yes
No
Consistent w
Functional Capacities (see DR381)?
Yes
No
 No
Accommodations Needed (not including job coaching)?
Yes
If Yes, describe:
Job Coaching Plan/Services Recommended: (must include job coach hours needed)
include reference to DR297JC
 Tools
 Adaptive Technology
Additional Needs:
Clothing
Benefits Counseling
 Other
Wage Reporting
Description (request DOR authorization, if needed):
SE Service Provider Signature:
Email Address:
Phone Number:
Date Signed:
Distribution:
DOR District Office (with Invoice)
DOR Counselor (via email or fax
)
Regional C
, see DR381
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.