"Customized Employment Assessment Form" - Delaware

Customized Employment Assessment Form is a legal document that was released by the Delaware Department of Labor - a government authority operating within Delaware.

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Supported Employment Assessment Addendum
Department of Labor
DIVISION OF VOCATIONAL REHABILITATION
CUSTOMIZED EMPLOYMENT ASSESSMENT
(Must Accompany DVR Supported Employment Assessment Form)
Name:
Date:
DVR Counselor:
Provider:
Instructions:
Complete section A for all consumers. Select an additional minimum of one section from sections B, C, & D to be
completed with the consumer.
Team Members:
Responsibilities of Each Team Member:
Consultants/Experts to Contact:
A. Home and Neighborhood:
People interviewed and relationship to the individual:
Information Obtained:
Page 1 of 4
Supported Employment Assessment Addendum
Department of Labor
DIVISION OF VOCATIONAL REHABILITATION
CUSTOMIZED EMPLOYMENT ASSESSMENT
(Must Accompany DVR Supported Employment Assessment Form)
Name:
Date:
DVR Counselor:
Provider:
Instructions:
Complete section A for all consumers. Select an additional minimum of one section from sections B, C, & D to be
completed with the consumer.
Team Members:
Responsibilities of Each Team Member:
Consultants/Experts to Contact:
A. Home and Neighborhood:
People interviewed and relationship to the individual:
Information Obtained:
Page 1 of 4
Observations of home, bedroom, belongings that seem relevant:
Specific chores and tasks performed at home:
Interests, collections, sports and hobbies observed:
Community activities (include freinds and family interactions):
Neighborhood mapping (transportation options, neighbors, community involvement, employers in the area):
Situations and activities that need to be avoided:
Page 2 of 4
B. Others to Be Interviewed:
What was learned?
Who?
Emerging talents, skills and interests:
C. Discovery Visit(s):
Identify a minimum of one additional location where this individual can be observed in activities that give context
to their interests, skills and abilities:
Observations (include supports required, situations to be avoided, and recommendations for additional
observation):
Page 3 of 4
D. Informational Interview(s):
What off-the-job supports will be needed and who might provide it?
List a minimum of 5 employers in this individual's community that have jobs that may fit in the individual's skills, interests and
abilities:
1.
2.
3.
4.
5.
Informational Interview 1:
Business:
Date and Time:
Contact Person & Title:
Phone:
Email:
Follow Up (What, who and by when):
Informational Interview 2:
Business:
Date and Time:
Contact Person & Title:
Phone:
Email:
Follow Up (What, who and by when):
Observations from Informational Interview(s):
E. Recommended Vocational Plan:
Total Hours Spent with Consumer:
Print Name:
Phone:
Date:
Signature:
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