12-Form 11 - Entity’s Physical Location(s) – Part B (VR3442B).pdf

VR3442B (12/22) Entity’s Physical Location Part B–General Information Service Contracts Page 1 of 3

Texas Workforce Commission Vocational Rehabilitation Services

Entity’s Physical Location(s) Part B General Information Service Contracts

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 for VR (Q) 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.

• This form must be completed for each physical location held by the applicant or contractor.

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

Application package

Update of information For example, new physical location for entity.

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:

Physical Location Information Physical location: Is a location the contractor owns, leases, or uses as dedicated space to provide goods and/or services to customers and/or attend in-person meetings with customers.

Physical location name:

Street address:

City:

County:

State:

ZIP code:

Mailing address: (only if it is different from the physical address)

City:

County:

State:

ZIP code:

Permits and Fire Inspection Reports

VR3442B (12/22) Entity’s Physical Location Part B–General Information Service Contracts Page 2 of 3

• Occupancy certificates or permits, building permits and fire inspection reports may be obtained from the landlord, if they are not in the possession of the applicant or contractor.

• When the contractor's local fire department does not conduct inspections, the contractor may request an inspection from the Texas Department of Insurance, State Fire Marshal's Inspection Services Division, 333 Guadalupe Street, Austin, Texas 78701, (512) 305-7900.

• When unable to obtain either the occupancy certificates or permits, building permits and fire inspection reports evidence of attempt(s) to collect must be attached to the form when submitted.

Occupancy certificate or permit, building permit submitted with this form? Yes No Agency Verified

Yes Initials:

If no, is supporting documentation attached to this form describing attempts made to obtain occupancy certificate or building permit? NA Yes No

Fire inspection report by a fire marshal submitted with this form? Yes No Agency Verified

Yes Initials:

If no, is supporting documentation attached to this form describing attempts made to obtain fire inspection reports? NA Yes No

Safety Requirements To ensure a customer’s safety when accessing a local business physical location must meet a minimum safety standard.

The physical location listed above has:

• Working smoke detectors with visible (flashing) and audible fire warning signals Yes No

• Non-expired fire extinguishers in accessible locations Yes No

• Diagrams posted that show accessible fire escape routes Yes No

• A plan to evacuate customers that require physical assistance Yes No

• A plan to arrange emergency medical services should a need arise Yes No

• Accessible aisles and work safety zones Yes No

• A plan implemented to identify and to safely secure hazardous or flammable materials Yes No

• Safety protocols in place for use of equipment and machinery Yes No

Accessibility

• Each entity is encouraged to complete the ADA Checklist for Existing Facilities to meet customers’ accessibility needs, but it is not required.

• In lieu of completing the ADA Checklist, and to ensure a customer’s access to an entity’s physical location for services, the physical location should meet the minimum accessibility standards listed below. When the below minimum standards do not meet customer’s individual needs, accommodations must be made for the customer so that services can be effectively delivered.

The physical location listed above has:

• Accessible/handicapped parking Yes No

• Accessible exterior route(s) to enter/exit the building (i.e. ramps, curb cuts, level) Yes No

• Accessible interior space in the building (i.e. level, wheelchair seating area, elevator, wide aisles, and doors) Yes No

• Accessible bathroom(s) Yes No If any above is answered no, describe the accommodation(s) that will be made to ensure customers have access to services:

Certification of Entity’s Physical Location Information http://www.adachecklist.org/doc/fullchecklist/ada-checklist-word-fillable-form.doc

VR3442B (12/22) Entity’s Physical Location Part B–General Information Service Contracts Page 3 of 3

I, the legally authorized representative, have the authority to certify:

• all information on this form is true and accurate;

• the physical location meets all of the minimum requirements related to ADA accessibility and safety standards above;

• arrangements will be made to address all accessibility needs of a customer during service delivery;

• acknowledgment all safety, unusual or unexpected events that compromises or may compromise the health and/or safety of individuals or the security of property must be reported TWC-VR through submission of VR3446, Incident Report to the contractors assigned Q or RPSS;

• the physical location stated above is in compliance with and will remain in compliance with TWC VR Standards for Provider Manual, and/or contract; and

• the entity acknowledges it must update this form anytime information changes.

Typed name:

Handwritten Signature:

X

Date:

Agency Use Only

Comments: Date each entry.

Reviewers of the Form Date Printed Name Title Initials https://twc.texas.gov/forms/index.html