"Community Based Assessment Agreement Form" - Nevada

Community Based Assessment Agreement Form is a legal document that was released by the Nevada Department of Employment, Training and Rehabilitation - a government authority operating within Nevada.

Form Details:

  • Released on June 1, 2014;
  • The latest edition currently provided by the Nevada Department of Employment, Training and Rehabilitation;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Nevada Department of Employment, Training and Rehabilitation.

ADVERTISEMENT
ADVERTISEMENT

Download "Community Based Assessment Agreement Form" - Nevada

Download PDF

Fill PDF online

Rate (4.3 / 5) 26 votes
REHABILITATION DIVISION
Community Based Assessment Agreement
(when CBA site is developed by a job developer)
Participant: ____________________________
Work Site: _________________________________
Case ID#: ______________________________
Supervisor: ________________________________
BVR Counselor: _________________________
Address: __________________________________
Job Developer: _________________________
__________________________________
Phone: ________________________________
Phone: ___________________________________
Type of Assessment/Position: ____________________________________________________________
Participant will be assessed in the following areas: ____________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Specific tools, clothing, documents, or other items needed for assessment at the work site location:
_____________________________________________________________________________________
_____________________________________________________________________________________
Participant’s transportation to/from worksite: _______________________________________________
Mutually agreed upon work schedule: _____________________________________________________
This agreement is entered into the _______________ day of ___________________ 20___, for a work
assessment of ______________ hours, beginning on _________________________.
This agreement will not become effective until signed below by the Rehabilitation Counselor, as
representative of the Division.
This agreement in no way obligates the work site to hire the participant. During the assessment,
worker’s compensation and wages will be paid by the Rehabilitation Division through a temporary
staffing agency.
The supervisor/worksite representative agrees to provide appropriate supervision to the participant and
weekly progress reports to the job developer or counselor.
This agreement is made in good faith and is not legally binding. It may be modified or terminated in
writing by any of the concerned parties. My signature on this document indicates agreement with the
stated conditions.
_________________________________
________________________________________
Participant
Date
Worksite Representative
Date
_________________________________
________________________________________
Rehabilitation Counselor
Date
Job Developer
Date
Phone: ___________________________
In case of emergency, if the job developer or counselor cannot be reached, please call ____________ Monday-
Friday (except holidays) and ask for the counselor’s supervisor or the supervisor in charge.
Community Based Assessment Agreement
Page 1 of 1
Effective: 06/01/2014
REHABILITATION DIVISION
Community Based Assessment Agreement
(when CBA site is developed by a job developer)
Participant: ____________________________
Work Site: _________________________________
Case ID#: ______________________________
Supervisor: ________________________________
BVR Counselor: _________________________
Address: __________________________________
Job Developer: _________________________
__________________________________
Phone: ________________________________
Phone: ___________________________________
Type of Assessment/Position: ____________________________________________________________
Participant will be assessed in the following areas: ____________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Specific tools, clothing, documents, or other items needed for assessment at the work site location:
_____________________________________________________________________________________
_____________________________________________________________________________________
Participant’s transportation to/from worksite: _______________________________________________
Mutually agreed upon work schedule: _____________________________________________________
This agreement is entered into the _______________ day of ___________________ 20___, for a work
assessment of ______________ hours, beginning on _________________________.
This agreement will not become effective until signed below by the Rehabilitation Counselor, as
representative of the Division.
This agreement in no way obligates the work site to hire the participant. During the assessment,
worker’s compensation and wages will be paid by the Rehabilitation Division through a temporary
staffing agency.
The supervisor/worksite representative agrees to provide appropriate supervision to the participant and
weekly progress reports to the job developer or counselor.
This agreement is made in good faith and is not legally binding. It may be modified or terminated in
writing by any of the concerned parties. My signature on this document indicates agreement with the
stated conditions.
_________________________________
________________________________________
Participant
Date
Worksite Representative
Date
_________________________________
________________________________________
Rehabilitation Counselor
Date
Job Developer
Date
Phone: ___________________________
In case of emergency, if the job developer or counselor cannot be reached, please call ____________ Monday-
Friday (except holidays) and ask for the counselor’s supervisor or the supervisor in charge.
Community Based Assessment Agreement
Page 1 of 1
Effective: 06/01/2014