"Consumer Placement, Job Coaching and Supported Employment Agreement Form" - Delaware

Consumer Placement, Job Coaching and Supported Employment Agreement Form is a legal document that was released by the Delaware Department of Labor - a government authority operating within Delaware.

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Download "Consumer Placement, Job Coaching and Supported Employment Agreement Form" - Delaware

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Job Placement Agreement
Job Coaching Agreement
Supported Employment Agreement
Revision
Department of Labor
DIVISION OF VOCATIONAL REHABILITATION
CONSUMER PLACEMENT, JOB COACHING
AND SUPPORTED EMPLOYMENT AGREEMENT
Name of Consumer:
Vocational Goal:
Date:
VR Counselor:
Provider:
Availability (Sunday – Saturday, Consider Alternative Work Schedules):
Transportation/Back Up Plan:
Desired Geographic Area(s):
Benefits and Wages Required:
Special Arrangements and Accommodations:
Instructions: This is both a needs determination and service coordination plan. In each category, identify the VR
consumer’s vocational needs.
TO BE ADDRESSED WITH THE CONSUMER, VR COUNSELOR AND CRP
I.
JOB DEVELOPMENT PHASE (14000, 17000 17001)
:
Development of job-seeking skills..................................................................................
1.
YES
NO
Develop a resume or employment proposal
Assist with dress and/or hygiene
Develop job-interviewing skills
Develop job-seeking skills
Other
Customer-specific job development..............................................................................
2.
YES
NO
Contact employers
Coordinate customer job interviews
Other
Job Analysis.............................................................................................................................
3.
YES
NO
Identify essential job functions
Develop job training plan
Other
*For supported employment cases, prior to job placement, all assessments must be complete. Additional support services
beyond the scope of this agreement may be contracted with a provider under employment success training services.
Rev. 1
Page 1 of 3
Job Placement Agreement
Job Coaching Agreement
Supported Employment Agreement
Revision
Department of Labor
DIVISION OF VOCATIONAL REHABILITATION
CONSUMER PLACEMENT, JOB COACHING
AND SUPPORTED EMPLOYMENT AGREEMENT
Name of Consumer:
Vocational Goal:
Date:
VR Counselor:
Provider:
Availability (Sunday – Saturday, Consider Alternative Work Schedules):
Transportation/Back Up Plan:
Desired Geographic Area(s):
Benefits and Wages Required:
Special Arrangements and Accommodations:
Instructions: This is both a needs determination and service coordination plan. In each category, identify the VR
consumer’s vocational needs.
TO BE ADDRESSED WITH THE CONSUMER, VR COUNSELOR AND CRP
I.
JOB DEVELOPMENT PHASE (14000, 17000 17001)
:
Development of job-seeking skills..................................................................................
1.
YES
NO
Develop a resume or employment proposal
Assist with dress and/or hygiene
Develop job-interviewing skills
Develop job-seeking skills
Other
Customer-specific job development..............................................................................
2.
YES
NO
Contact employers
Coordinate customer job interviews
Other
Job Analysis.............................................................................................................................
3.
YES
NO
Identify essential job functions
Develop job training plan
Other
*For supported employment cases, prior to job placement, all assessments must be complete. Additional support services
beyond the scope of this agreement may be contracted with a provider under employment success training services.
Rev. 1
Page 1 of 3
JOB PLACEMENT AND RETENTION PHASES (15000, 16000, 17000,17001):
II.
Direct intervention with employer..................................................................................
4.
YES
NO
Assist customer with interview
Orient customer to the job
Orient customer to work schedule
Develop initial natural supports
Follow up with employer during the first 90 days of employment
Other
5. Direct connection with consumer is required for employment payment point
Proof of employment(e.g. pay stub,letter of employment from employer, bank statement
identifying direct deposit from employer. Other acceptable form of verification ie. 1099
estimated yearly taxes.
Transportation coordination/training............................................................................
6.
YES
NO
Develop transportation arrangements
Other
Coordination of financial issues.......................................................................................
7.
YES
NO
Assist with coordination of financial support services
(SSA, other public/private sources)
Coordination of extended/follow along services (*Supported Employment Only)
III.
JOB COACHING AND STABILIZATION PHASES (8000, 17000, 17001)
8. Employment-related personal skills training.............................................................................
YES
NO
Train customer on specific work behaviors to the satisfaction of the employer
Work schedule time management training
Workplace communication skills training
Other
9. Maintenance of appropriate work and interpersonal behaviors........................................
YES
NO
Develop and implement fading plan
Maintain appropriate behaviors to the satisfaction of the employer
Support to relearn job tasks
Short-term training follow-up with customer
Other
9. Other training needs/comments (specify)...................................................................................
YES
NO
Banking and income management training
Coordinate job accommodations and natural supports
Research and recommend assistive technology
Training in the use of public transportation
Other
Other
Page 2 of 3
Number of Total Job Coaching Hours Anticipated Under this Phase (If Applicable):
10. Applied Behavioral Analysis and Behavioral Supports Recommended............................
YES
NO
11. Customized Employment Recommended (*Supported Employment Only)..............
YES
NO
12. Formalized Assistive Technology Evaluation Recommended..............................................
YES
NO
*For supported employment cases, prior to job placement, all assessments must be complete. Additional support services
beyond the scope of this agreement may be contracted with a provider under employment success training services.
SIGNATURE OF THE PARTICIPANTS INDICATES AGREEMENT WITH THE CONSUMER'S GOALS
Consumer Name:
Consumer Signature:
Date:
Parent/Guardian
Signature
:
Date:
(if required)
Provider Name:
Provider Signature:
Date:
Title:
DVR Counselor
Date:
Signature:
COMMENTS:
*For supported employment cases, prior to job placement, all assessments must be complete. Additional support services
beyond the scope of this agreement may be contracted with a provider under employment success training services.
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