ESBD_515780_1778790318841_Attachment 09-VR3490 Temporary Waiver of Qualifications.pdf

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Texas Workforce Commission Vocational Rehabilitation Services

Temporary Waiver of Qualifications Instructions:

• The Temporary Waiver of Qualifications is not effective until approved by the Director of Vocational

Rehabilitation Division.

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

• Form must be signed by the provider’s Director prior to submitting to VRS.

• The provider’s Director completes the Temporary Waiver of Qualifications when requesting use of a staff person who does not hold a required qualification, including UNTWISE Credentials, for a defined period of time until the staff person gains the required qualification as defined in the Standards for Providers. Note: The Temporary Waiver of Qualifications is limited only to the time indicated and approved on the form.

• Submit the completed and signed form to the Regional Quality Assurance Specialist (Regional Q) or the Regional Program Support Specialist (RPSS) for approval. The Regional Q and RPSS will review and obtain required regional approval and submit the form to the VRS.program.contract.approval@twc.texas.gov.

• After Director of Vocational Rehabilitation Division approval, the Regional Q or RPSS will maintain a copy of the form in the contractor’s file and will provide a copy to the contractor. The contractor must submit a copy of the form with any applicable invoice for services provided by the staff person listed in the form.

Note: Temporary Waivers are not available for UNTWISE Endorsements.

Contractor Information

TWC contract number:

Texas identification number (TIN):

Legal name:

Doing Business As (DBA) name:

Main phone number:

General email address:

Entity’s (contractor’s) legally authorized representative’s name:

Street address (include suite number, if any):

City:

State:

ZIP code:

Director’s Name:

Director’s email:

Director’s phone number:

EXAMPLE

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Staff Person’s Information First name: Last name:

List the VR-SFP section where the required qualifications are listed:

If request is to waive a credential, complete the following:

Type of Requested Credential to be Waived:

Enrollment Dates of Credential Class

Anticipated Completion Date

TWC-TWS-VRS

Approved

Date Waiver Expires

Job Skills Training Yes No NA Job Placement Yes No NA

Supported Employment Yes No NA

Self-Employment Yes No NA Work Readiness (formally Vocational Adjustment Training) Yes No NA

Director Yes No NA

CBTAC (self-employment) Yes No NA Note: Attach proof of enrollment into required credential course.

If not listed above, describe the specific qualification the staff person does not meet.

Describe the staff person’s abilities, skills, work experience and education related to the services provided associated to the requested service(s) to receive a Temporary Waiver.

Is an accurate and complete VR3455, Program Staff Information Form, for the above person on file with the Contract Manager and Regional Quality Assurance Specialist or Regional Program Support Specialist? Yes No

Director’s Justification for Wavier Describe why the provider is requesting the wavier:

By signing below, I verify that I provided the Director’s justification above.

Director’s signature:

X Date:

Authorized Service Provider Representative Signature A legally authorized representative is the person who is authorized to sign contracts and other official documents for the entity.

By signing below, I, the entity’s legally authorized representative, acknowledge:

• this is a temporary waiver;

• the need to train and/or hire credentialed staff members; and

• the continued lack of credentialed staff may result in termination of our contract.

Entity’s legally authorized representative’s signature:

Authorizations and Signatures Regional Quality Assurance Specialist or Regional Program Support Specialist

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How was the waiver need determined by Q/RPSS?

Regional Quality Assurance Specialist or Regional Program Support Specialist agrees with the contractor’s justification and need for use of a non-credentialed staff person.

Approved Denied

If the response above is denied, the Regional Quality Assurance Specialist or Regional Program Support Specialist will provide an explanation below:

By printing my name below, I, the Regional Quality Assurance Specialist or Regional Program Support Specialist verify the information above.

Regional Director By printing my name below, I, the Regional Director, verify that I agree with the above request.

Director of Vocational Rehabilitation Services By printing my name below, I, the Director of Vocational Rehabilitation Services, verify that I agree with the Temporary Waiver of Credential information on this form.

Additional Comments, if any