10-Form 12 - Provider Staff Info Form(s) Supporting Documentation (VR 3455).pdf

VR3455 (11/23) Provider Staff Information Form Page 1 of 5

Texas Workforce Commission Vocational Rehabilitation Services

Provider Staff Information Form Instructions:

• Each entity must have an accurate and current VR3455, Provider Staff Information Form, on file for all personnel (including contracted personnel) and the director appointed by the legal authorized representative that interact with TWC Vocational Rehabilitation customers under a TWC Vocational Rehabilitation contract.

• For response to an Electronic State Business Daily (EBSD) posting, follow the instructions in the ESBD posting; otherwise, submit updated forms to the Quality Assurance Specialist for VR (Q) or Regional Program Support Specialist (RPSS).

• Follow the instructions on the form and in the TWC VR Standards for Providers.

• The director on record with TWC and appointed by the entity’s legally authorized representative signs this form verifying the staff member's qualifications as documented in the VR Standards for Providers (VR-SFP) manual.

• Submit the updated form within 30 days of any of the following: after hiring staff, significant change in a staff member’s job duties, change in staff qualifications, or a staff member is separated from employment.

• Type all information on the form using a computer and obtain all required signatures.

• Complete all sections of the form. Record “N/A” (not applicable) if a question does not apply.

• Keep a copy of the completed the VR3455, attachments, and supporting documentation for your records.

Reason for Submission

Date of submission: Solicitation ID: or Contract #:

Application package New hire Separation of staff person Update of information (For example, qualifications change.)

Other: Specify:

Entity’s Information Entity: The business that is requesting or has been granted the bilateral contract with TWC to provide services on behalf of VR customers.

Entity’s legal name:

Entity’s “doing business as” (DBA) name:

Provide at least one of the following:

Employer Identification Number (EIN) (9 digits, issued by IRS):

Last four digits of the sole proprietor’s Social Security Number:

Staff Person’s Information For the purpose of this form, “staff person” refers to persons classified as employees or independent contractors working for the entity that has the TWC bilateral contract.

Staff person’s first name: Staff person’s last name:

Other names used:

Experience and Skills

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UNTWISE Endorsements held: N/A Autism Blind Brain Injury Other:

Describe your experience and skills working with individuals with disabilities, including disability groups.

Language Skills Select all languages in which the staff person is fluent.

American Sign Language (ASL) Hindi Korean Tagalog Arabic Japanese Persian Urdu Chinese English Spanish Vietnamese Other:

Does the staff person read braille? Yes No Secondary Education

Select one: High school diploma General Educational Development (GED) certification

College or University History Record earned associate’s, bachelor’s, master’s, or doctoral degrees.

Copies of diploma or transcriptions must be submitted with this form when associated with a qualification.

N/A. Staff person does not have a college or university education history.

Name of College or

University Degree

Received Major (and Minor, if applicable) Verified by

SME, QASVR, or RPSS Yes Initials:

Yes Initials:

Yes Initials:

Record all incomplete associate, bachelor’s, master’s, or doctoral degrees.

Copies of transcriptions must be submitted with this form.

Name of College or University

Incomplete Degree

Total Number of Hours Completed

Verified by SME, QASVR, or RPSS

Yes Initials:

Yes Initials:

Yes Initials:

Credentials, Certifications, and Licenses Record all of the following:

• UNTWISE Credentials and Endorsements,

• Center for Social Capital Certified Business Technical Assistance Consultant (CBTAC) certification,

• Sign Language Proficiency Interview (SLPI) certifications, and

• Other credentials, certifications, or licenses such as Licensed Baccalaureate Social Worker (LBSW), Licensed Master Social Worker (LMSW), and Licensed Clinical Social Worker (LCSW).

Copies of credentials, certifications, and licenses must be submitted with this form.

N/A. The staff person has no credentials, certifications, or licenses.

The staff person is the director appointed by the legally authorized representative of the entity.

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Credential, Endorsement, Certification, or License Title

Credential, Endorsement

Certification, or License Number

Expiration Date Verified by SME, QASVR, or RPSS

Yes Initials:

Yes Initials:

Yes Initials:

Yes Initials:

Yes Initials:

Yes Initials:

Yes Initials:

Employment Experience Provide paid and unpaid work experience. Résumés will not be accepted in place of this section.

N/A. Staff Person does not have employment experience applicable to service(s) provision.

Employer:

Employed dates: from to Nature of duties:

Employer:

Employed dates: from to Nature of duties:

Employer:

Employed dates: from to Nature of duties:

Services to be Provided by the Staff Person Select a service only if you meet the minimum qualifications as described in the TWC VR Standards for Providers. Selecting services you are not qualified to provide could result in adverse actions against the entity.

N/A. The staff person is not providing direct service for VR customers.

Select all that apply. Agency Use Only: Qualification verified by SME, QASVR or RPSS

Blind Services Assistive Technology Evaluation for Sight-Related Disabilities Yes No Initials:

Assistive Technology Training for Sight-Related Disabilities Yes No Initials:

Diabetes Self-Management Education Yes No Initials:

Independent Living Services for Older Individuals who are Blind Yes No Initials:

Orientation and Mobility Training (O & M) Yes No Initials:

Employment Services Career Planning Assessment (CPA) Yes No Initials:

Environmental Work Assessment (EWA) Yes No Initials:

Job Placement (Bundled and Non-bundled) Yes No Initials:

Job Skills Training (JST) Yes No Initials:

Personal Social Adjustment Training (PSAT) Yes No Initials:

Self-Employment Yes No Initials:

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Supported Self-Employment Yes No Initials:

Supported Employment (SE) Yes No Initials:

Vocational Adjustment Training (VAT) Yes No Initials:

Vocational Evaluation (VE) Yes No Initials:

Work Adjustment Training (WAT) Yes No Initials:

Work Experience Placement (WEP) Yes No Initials:

Work Experience Training (WET) Yes No Initials:

Customized Employment Services Customized Employment Services Yes No Initials:

Pre-Employment Transition Services (Pre-ETS) Pre-Employment Transition Services (Pre-ETS) Yes No Initials:

Project SEARCH Services Project SEARCH Asset Discovery Service Yes No Initials:

Project SEARCH Skills Training Service Yes No Initials:

Project SEARCH Job Placement Service Yes No Initials:

Mental Health and Substance Use Services Supportive Residential Services for Persons in Recovery Yes No Initials:

Wellness Recovery Action Plans (WRAP) Yes No Initials:

Group Skills Training for Older Individuals who are Blind (OIB) Senior Keys to Independence Program (S.K.I.P.) Yes No Initials:

Use if Service not listed Above Other: Yes No Initials:

Other: Yes No Initials:

Agency Use Only: Comments:

Transportation of VR Customers Do you plan to transport VR customers in a personal vehicle while providing services? Yes No Insurance Information Agency Use Only

Q or RPSS Verified Insurance

Name of Carrier:

Expiration Date:

Proof of Insurance attached? Yes No Yes No

Background Checks Contractors that will provide goods or services directly to VR customers must run a criminal background check on each staff member who will interact with any VR customer. This includes any staff who have any communication or other contact whether in person, on paper, by voice, by sign language, electronically, or any other method. The only exception is for staff who never communicate with or are physically present with a VR customer.

Based on the definition above, will the staff person interact with VR customers? Yes No

Verification Statements Staff Person I, the person named on this staff information form, certify that I have:

• completed the form and acknowledge that a new complete VR3455, Provider Staff Information Form, must be submitted to TWC whenever the information on this form changes;

• reviewed the TWC VR Standards for Providers and confirm that I meet the qualifications for all services checked in the “Services Provided by the Staff Person” section of this form;

• attached proof of all diplomas, transcripts, credentials, certifications, specialty endorsements, and licenses listed on this form;

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• read and understood, and will abide by, the current TWC VR Standards for Providers and by all updates and changes made to it; and

• submitted proof of carrying of minimum liability requirements of the Texas Department of Insurance, if planning to transport the customer in personal vehicle.

I acknowledge that failure to abide by the entity’s TWC contract requirements and TWC VR Standards for Providers might cause adverse consequences for the entity, such as denial of payments, recoupment of payments, suspension of service provisions to VR customers, or loss of an awarded contract.

Typed name of staff member:

Handwritten or digital signature of staff member:

X

Date:

Director’s Signature (When the legal representative is also the Director, signature is still required) I, the director appointed by the entity’s legally authorized representative, do have the authority to supervise this staff person, and certify that:

• all information recorded by the staff person named on this form has been verified;

• I have reviewed the TWC VR Standards for Providers and the contract requirements, and I agree that the staff person meets the qualifications for all services checked;

• a criminal history check has been conducted on this employee before they interact with any VR customer, that an updated background check will be obtained every three years, and that the entity will comply with the background checks policy in the TWC VR Standards for Providers.

• a copy of this form and supporting documentation is in the personnel file of the staff person and will be made available to TWC upon request;

• I acknowledge that a new complete VR3455 must be submitted to TWC whenever the information on this form changes; and

• I acknowledge that failure to abide with the entity’s TWC contract requirements and TWC VR Standards for Providers might cause adverse consequences for the entity, such as denial of payments, recoupment of payments, suspension of service provision to VR customers, or loss of an awarded contract.

Typed name:

Title:

UNTWISE Credential Number:

Date the UNTWISE Director Credential expires:

Handwritten or digital signature of Director:

X

Date:

Agency Use Only Comments:

Reviewers of the application:

Date Name Title Initials