"Dvr Job Placement - Coaching and Supported Employment Progress Report Form" - Delaware

The Delaware Department of Labor has released this version of the "Dvr Job Placement - Coaching and Supported Employment Progress Report Form" on June 1, 2015.

This form may be used by all Delaware residents: download the printable PDF by clicking the link below and use it according to the applicable legal guidelines.

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Download "Dvr Job Placement - Coaching and Supported Employment Progress Report Form" - Delaware

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Department of Labor
Job Placement Progress
Job Coaching Progress
DIVISION OF VOCATIONAL REHABILITATION
Supported Employment Progress
Evidence Based SE Progress
(Must Accompany DVR-7 Authorization in Order to Receive Payment)
Amendment
Progress Report for:
(DVR Consumer)
(DVR Counselor)
Case Manager(s) - DDDS, DSAMH (if applicable):
Provider Organization & Name of Person Completing Report:
SERVICE STATUS (DVR requires a monthly progress report for all services being provided by a community rehabilitation program):
Traditional or Competitive Services:
Supported Employment Services:
Monthly Progress
Monthly Progress
* Job Development
Placement (SE 2)
(*Resume or Employment Proposal Attached)
4-week Retention (SE 3)
Placement verified via attached documentation
Stabilization (SE 4)
(within 30 days of placement)
30 Days Employment
Job Coaching
60 Days Employment
30 Days Employment
Closure (90-Days, SE 5)
60 Days Employment
90 Days Employment (Closure)
6 Month Bonus (SE 6)
*Dates Covered:
Employment Start Date:
Employer:
Job Title:
Supervisor's Name:
Address:
Hourly Wage:
Telephone #:
Benefits:
Hours Per Week:
Work Schedule:
Job Description/Duties
Rev. 06/2015
Department of Labor
Job Placement Progress
Job Coaching Progress
DIVISION OF VOCATIONAL REHABILITATION
Supported Employment Progress
Evidence Based SE Progress
(Must Accompany DVR-7 Authorization in Order to Receive Payment)
Amendment
Progress Report for:
(DVR Consumer)
(DVR Counselor)
Case Manager(s) - DDDS, DSAMH (if applicable):
Provider Organization & Name of Person Completing Report:
SERVICE STATUS (DVR requires a monthly progress report for all services being provided by a community rehabilitation program):
Traditional or Competitive Services:
Supported Employment Services:
Monthly Progress
Monthly Progress
* Job Development
Placement (SE 2)
(*Resume or Employment Proposal Attached)
4-week Retention (SE 3)
Placement verified via attached documentation
Stabilization (SE 4)
(within 30 days of placement)
30 Days Employment
Job Coaching
60 Days Employment
30 Days Employment
Closure (90-Days, SE 5)
60 Days Employment
90 Days Employment (Closure)
6 Month Bonus (SE 6)
*Dates Covered:
Employment Start Date:
Employer:
Job Title:
Supervisor's Name:
Address:
Hourly Wage:
Telephone #:
Benefits:
Hours Per Week:
Work Schedule:
Job Description/Duties
Rev. 06/2015
DVR Job Placement - Coaching and Supported Employment Progress
DESCRIPTION/NOTES - INCLUDE JOB APPLICATIONS COMPLETED AND INTERVIEWS (If supported employment, report %
follow up level required; barriers to employment; natural and positive behavioral supports [if applicable] relating to
milestone reported.)
Narrative format - Report to reflect Placement Agreement goals: Date each entry, include type of contact (phone, face
to face, etc), contact attempts, identify persons and places contacted, describe events and progress made, and the plan
for next steps. MONTHLY REPORTS ARE DUE WITHIN 14 DAYS OF EACH MONTH OF SERVICE PROVIDED.
Services - Job Placement Agreement Goals
Summary
I. JOB DEVELOPMENT PHASE - 14000, 17000 17001
1. Development of job-seeking skills
Develop a resume or employment proposal
Assist with dress and/or hygiene
Develop job-interviewing skills
Develop job-seeking skills
Other -
2. Customer-specific job development
Contact employers
Coordinate customer job interviews
Other -
3. Job Analysis
Identify essential job functions
Develop job training plan
Other -
II. JOB PLACEMENT AND RETENTION PHASES - 15000, 16000, 17000,17001
4. Direct intervention with employer
Assist customer with interview
Orient customer to the job
Orient customer to work schedule
Develop initial natural supports
Follow-up with employer during first 90 days of
employment
Other -
Direct contact with consumer is required for
5.
employment payment point within 30 days of hire.
Proof of employment (e.g. pay stub, employer letter of
verification, DOL Employment Verification, bank
statement of direct deposit of wages, or other
acceptable verification, i.e. 1099 Statement or Equifax
Verification Services.)
Other -
DVR Job Placement - Coaching and Supported Employment Progress
6. Transportation coordination/training
Develop transportation arrangements
Other -
7. Coordination of financial issues
Assist with coordination of financial support services
(SSA, other public/private sources)
Coordination of extended/follow-along services
(*Supported Employment Only)
Other -
III. JOB COACHING AND STABILIZATION PHASES - 8000, 17000, 17001
8. Employment-related personal skills training
Train customer on specific work behaviors to the
satisfaction of the employer
Work schedule time management training
Workplace communication skills training
Other -
9. Other training needs/comments (specify)
Banking and income management training
Coordinate job accommodations and natural supports
Research and recommend assistive technology
Training in the use of public transportation
Other -
RATING SCALE: (Check one rating for each item)
Attendance/
Ability to
Satisfactory
Unsatisfactory
Satisfactory
Unsatisfactory
Punctuality
Organize Work
Completes Tasks/
Appearance
Satisfactory
Unsatisfactory
Satisfactory
Unsatisfactory
Assignments
Social Interaction
Acquires Job Skills
Satisfactory
Unsatisfactory
Satisfactory
Unsatisfactory
with Co-Workers
Needed to Perform
Follows Work Rules
Interaction with
Satisfactory
Unsatisfactory
Satisfactory
Unsatisfactory
and Procedures
Supervisors
Ability to Follow
Overall Job
Satisfactory
Unsatisfactory
Satisfactory
Unsatisfactory
Instructions
Performance
For any items of concern per the rating scale, please specify the issue and indicate how
progress will be addressed through the use of assistive technology, accommodations and/or
natural supports:
Total estimated hours of services provided to consumer for this reporting period:
Service Provider Representative Name (Print)
Service Provider Representative Signature
Date
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