"Community Based Work Assessment Form" - Delaware

This Delaware-specific printable "Community Based Work Assessment Form" is a part of the legal paperwork issued by the Delaware Department of Labor.

Download the up-to-date PDF by clicking the link below and mail it as per the guidelines provided by the department.

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Download "Community Based Work Assessment Form" - Delaware

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Supported Employment Assessment
Department of Labor
DIVISION OF VOCATIONAL REHABILITATION
COMMUNITY BASED WORK ASSESSMENT
(Must Accompany DVR - 7 Authorization in Order to Receive Payment)
Name of Consumer:
Date:
DVR Counselor:
Provider:
I.
PRE ASSESSMENT SUMMARY OF INFORMATION - with consumer and school/family/caregiver
network, in which occupational choices and concerns are discussed and identified; and includes job
preferences, work conditions desired and disliked.
Family/Network of Support:
Strengths:
Interests:
Job Environment (Likes/Dislikes):
Job Choice/Preferences:
Page 1 of 7
Supported Employment Assessment
Department of Labor
DIVISION OF VOCATIONAL REHABILITATION
COMMUNITY BASED WORK ASSESSMENT
(Must Accompany DVR - 7 Authorization in Order to Receive Payment)
Name of Consumer:
Date:
DVR Counselor:
Provider:
I.
PRE ASSESSMENT SUMMARY OF INFORMATION - with consumer and school/family/caregiver
network, in which occupational choices and concerns are discussed and identified; and includes job
preferences, work conditions desired and disliked.
Family/Network of Support:
Strengths:
Interests:
Job Environment (Likes/Dislikes):
Job Choice/Preferences:
Page 1 of 7
Criminal History Indicated:
Benefits Counseling Completed/Recommended:
If the consumer is still enrolled in school, has information been gathered from the school district? If
so, please include a description of the information provided by school personnel and dates received.
Prior to engaging in the work assessment, what are the work tasks/behaviors to be observed?
II.
WORK HISTORY OR PAST EXPERIENCES -
Summary of skills learned from pervious jobs or work related tasks in the home or community:
Page 2 of 7
Summary of Support Needs/Barriers Identified Previously:
III.
SITUATIONAL ASSESSMENTS - List each situational assessment, particulars of the job, how well
did the consumer perform or not perform; consumers like or dislikes; discuss barriers to
successful employment (i.e., family issues, transportation, salary issues, hours, functional
abilities, worksite accommodations, supports needed, etc.)
A.
Company:
Position:
Duties:
Hours Spent On Site with Consumer:
Date(s):
Summary:
B.
Company:
Position:
Duties:
Hours Spent On Site with Consumer:
Date(s):
Summary:
Page 3 of 7
C.
Company:
Position:
Duties:
Hours Spent On Site with Consumer:
Date(s):
Summary:
D.
Company:
Position:
Duties:
Hours Spent On Site with Consumer:
Date(s):
Summary:
Page 4 of 7
IV.
SUMMARY OF FUNCTIONING - Based on the information in Secions I, II, and III, provide a summary of
the individual's ability to function in the workplace.
(The following are rated 1 through 5 according to observation; 1=minimal, 3=average,
5=superior, n/a=not applicable)
A. Interests
Enjoys working with people
1.
1
2
3
4
5
n/a
Enjoys doing paperwork
2.
1
2
3
4
5
n/a
Enjoys working outdoors
3.
1
2
3
4
5
n/a
Enjoys working with their hands
4.
1
2
3
4
5
n/a
Enjoys problem solving
5.
1
2
3
4
5
n/a
Enjoys working independently
6.
1
2
3
4
5
n/a
B. Ability to Perform Tasks
Dress/appearance
1.
1
2
3
4
5
n/a
Level of reinforcement needed
2.
1
2
3
4
5
n/a
Level of Supervision needed
3.
1
2
3
4
5
n/a
4.
Multitasking
1
2
3
4
5
n/a
Level of Initiating tasks
5.
1
2
3
4
5
n/a
Level of Tolerance/endurance
6.
1
2
3
4
5
n/a
Level of Sequencing
7.
1
2
3
4
5
n/a
Ability to Switch Tasks
8.
1
2
3
4
5
n/a
Ability to Interact with Coworkers
9.
1
2
3
4
5
n/a
Family Support
10.
1
2
3
4
5
n/a
Reading Ability
11.
1
2
3
4
5
n/a
Writing Ability
12.
1
2
3
4
5
n/a
Mathematical Ability
13.
1
2
3
4
5
n/a
Accommodations Required
14.
1
2
3
4
5
n/a
Assistive Technology Required
15.
1
2
3
4
5
n/a
Page 5 of 7
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