12-Form 08-Entity Headquarters Information-Services (VR 3441B).pdf

VR3441B (04/23) Entity Headquarters Information Part B – Services Page 1 of 4

Texas Workforce Commission Vocational Rehabilitation Services

Entity Headquarters Information Part B - Services d

Instructions:

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

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

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

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

• Keep a copy of your submitted form with attachments and supporting documentation for your records.

Reason for Submission Date of submission: Solicitation ID: or Contract #:

Application package

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:

Location of Entity’s Headquarters Headquarters: The location where the entity stores customer records and performs administrative responsibilities as required by the bilateral contract with TWC. Each entity must have a designated headquarters location. \ Street address:

City:

County:

State:

ZIP code:

Mailing address: (if different from physical address)

City:

County:

State:

ZIP code:

Email address, if any:

Web address (if applicable):

VR3441B (04/23) Entity Headquarters Information Part B – Services Page 2 of 4

Entity’s Staff Experience and Skills

UNTWISE Endorsements held by entity staff:

N/A Autism Blind Brain Injury Other:

Describe the entity’s staff experience and skills working with individuals with disabilities, including disability groups. Record N/A if no experience or skills.

Entity’s Staff 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:

Do any staff read braille? Yes No Describe the staff person’s experience and skills for any areas identified above. The description should explain the staff person’s experience and skills in the identified areas.

Services

The entity must have at least one staff member who meets the staff qualifications for any service marked below.

List only service in the solicitation identified on page one of this form.

For each service below indicate:

• if the service is in an existing contract or

• if requesting the service be included in a new contract or an amendment to an existing contract.

N/A No services included in the application or contract.

Select all that apply.

Requesting service be in contract

Agency Use Only:

Qualification verified by SME, QASVR or RPSS

Benefits Planning Services Medicaid Buy-In Yes Initials:

Revision to Supplemental Security Income and/or Title II Benefits Summary and Analysis/Work Incentive Plan or Veteran’s Benefits Summary and Analysis/Work Incentive Plan

Yes Initials:

Supplemental Security Income and/or Title II Benefits Information and Referral Yes Initials:

Supplemental Security Income and/or Title II Benefits Summary and Analysis/Work Incentive Plan Yes Initials:

Supplemental Security Income Student Earned Income Exclusion Yes Initials:

Supplemental Security Income Impairment-Related Work Expense Yes Initials:

Supplemental Security Income Blind Work Expense Yes Initials:

VR3441B (04/23) Entity Headquarters Information Part B – Services Page 3 of 4

Supplemental Security Income Plan to Achieve Self-Support Yes Initials:

Supplemental Security Income Property Essential to Self- Support Yes Initials:

Title II Plan to Achieve Self-Support Yes Initials:

Title II Impairment-Related Work Expense Yes Initials:

Title II Subsidy or Special Condition Yes Initials:

Veteran’s Supplemental Security Income and/or Title II Benefits Summary and Analysis/Work Incentive Plan Yes Initials:

Blind Services Assistive Technology Evaluation Yes Initials:

Assistive Technology Training for Sight-Related Disabilities Yes Initials:

Diabetes Self-Management Education Yes Initials:

Independent Living Services for Older Individuals who are Blind Yes Initials:

Orientation and Mobility Training (O & M) Yes Initials:

Customized Employment Services

Customized Employment Services Yes Initials:

Communication Access

Interpreter Services for Deaf and Hard of Hearing for TWC-VR Customers Yes Initials:

Interpreter Services for Deaf and Hard of Hearing for TWC-VR Customers for College and Universities Yes Initials:

Realtime Translation (CART) for TWC-VR Customers Yes Initials:

Realtime Translation (CART) for TWC-VR Staff Yes Initials:

Employment Services Career Planning Assessment (CPA) Yes Initials:

Environmental Work Assessment (EWA) Yes Initials:

Job Placement (Bundled and Non-bundled) Yes Initials:

Job Skills Training (JST) Yes Initials:

Personal Social Adjustment Training (PSAT) Yes Initials:

Self-Employment Yes Initials:

Supported Self-Employment Yes Initials:

Supported Employment (SE) Yes Initials:

Vocational Adjustment Training (VAT) Yes Initials:

Vocational Evaluation (VE) Yes Initials:

Work Adjustment Training (WAT) Yes Initials:

Work Experience Placement (WEP) Yes Initials:

Work Experience Training (WET) Yes Initials:

Employment Supports for Brain Injury (ESBI) Employment Supports for Brain Injury (ESBI) Yes Initials:

Mental Health and Substance Use Services Supportive Residential Services for Persons in Recovery Yes Initials:

Wellness Recovery Action Plans (WRAP) Yes Initials:

Pre-Employment Transition Services (Pre-ETS) Pre-Employment Transition Services (Pre-ETS) Yes Initials:

VR3441B (04/23) Entity Headquarters Information Part B – Services Page 4 of 4

Project SEARCH Services Project SEARCH Asset Discovery Service Yes Initials:

Project SEARCH Skills Training Service Yes Initials:

Project SEARCH Job Placement Service Yes Initials:

Group Skills Training for Older Individuals who are Blind (OIB) Senior Keys to Independence Program (S.K.I.P.) Yes Initials:

Use if service not listed above Other: Yes Initials:

Other: Yes Initials:

Signatures I, the legally authorized representative, have been named by the entity and have the authority to certify

• when services are included on this form, the Entity has at least one person who meets the qualifications for each service identified above

• the information provided in this form is complete and accurate, and

• the legal entity is in compliance with all the terms in the Electronic State Business Daily Agency

Posting notice, TWC VR Standards for Provider manual, and/or contract, when awarded.

Typed name:

Handwritten Signature:

X

Date:

Agency Use Only

Comments:

Reviewers of the Form Date Printed Name Title Initials