ESBD_516615_1778878791207_Attachment 03-VR2891 ILS-OIB Customer Serv.pdf

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Texas Workforce Commission Vocational Rehabilitation Services

ILS-OIB Customer Services Progress Report

Independent Living Services for Older Individuals who are Blind (ILS-OIB) Customer Information

Customer name:

Case ID:

Service authorization number:

ILS-OIB worker name:

Independent Living Skills (ILS) Provider:

Beginning date of service:

Ending date of service:

Select the services provided:

Application Assessment

IL Skills Training Services

Final IL Skills training services report

Progress Report

A narrative report detailing the services provided during the reporting period including:

• identification of the customer's needs, strengths, and limitations for independent living;

• measurable goals, objectives, and timelines;

• progress made toward the customer’s goals;

• the number of hours the customer participated in training;

• the provider's observations, comments, and recommendations; and

• specific references to the services requested by the customer's ILS-OIB worker.

Provider Signatures

Independent Living Services Provider Signature (Required for all providers)

By signing below, I, the Independent Living Services Provider, certify that:

• the above dates, times, and services are accurate;

• I personally facilitated all training, meeting all outcomes required for payment and documented the service, as prescribed in the VR-SFP and service authorization;

• Verification of the customer’s satisfaction and service delivery obtained as stated above;

• I maintain the staff qualifications required for an Assistive Technology Trainer as described in the VR-SFP or Service Authorization; and

• I signed my signature and entered the date below.

Provider typed name:

Signature: (See VR-SFP 3 on Signatures

X

Date signed:

EXAMPLE

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Director Credentials and Signature

By signing below, I, the Director, certify that:

• I ensure that the services were provided by qualified staff, met all outcomes required for payment, and services were documented, as prescribed in the VR-SFP and service authorization;

• I maintain UNTWISE Director credential, as prescribed in VR-SFP;

• I signed my signature and entered the date below.

Typed or printed name:

Signature: (See VR-SFP 3 on Signatures)

X

Date Signed:

Select all that apply: UNTWISE Credentialed with ID:

VR3490-Waiver Proof Attached

VRS Use Only

If any question below is answered no or if the report or supporting documentation is missing or incomplete, return the invoice to the provider with the VR3460. Make a case note to document the results of the review and the date VR3460 was sent to provider, when applicable.

Technical Review to Verify Provider Qualifications

(Completed by any VR staff such as RA, CSC, VR Counselor)

Director’s Credential:

UNTWISE website or attached VR3490 verifies, for the dates of service, the director listed above:

maintained or waived the UNTWISE Director Credential did not hold a valid UNTWISE Director Credential

Verification of Service Delivery

Technical Review (completed by any VR staff such as RA, CSC, VR Counselor)

Verified that the report is accurately completed per form instructions Yes No

Verified that the service(s) was provided within service date of SA and as stated in the VR Standards for Providers and/or the SA

Yes No

When applicable, verify a copy of an approved VR3472 is attached to the report?

NA Yes No

Verified that the assessment on Independent Living and Communication Skills was completed with customer.

Yes No

Verified that attendance was recorded and includes the total number of hours the customer participated in services

Yes No

Verified that the appropriate fee(s) was invoiced. Yes No

Printed name of VR staff member making verification:

1. Date: 2. Date:

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VR Counselor Review

Verified that all necessary accommodations, compensatory techniques, and special needs were provided as necessary, for the customer to successfully participate in the services.

Yes No

Verified that customer’s performance, skills, and needs were assessed, and results summarized for the reporting period.

Yes No

Verified that goals and objectives are measurable and established for all skills to be addressed.

Yes No

Verified that a projected timeline to include training hours has been established for each goal.

Yes No

By typing or printing your name, the VRC verifies:

Verified the completion of the technical review,

• services provided met the customer’s individual needs,

• services provided met specifications in the VR-SFP and on the SA, and

• customer’s or legally authorized representative’s satisfaction with services received.

Approve to pay invoice Do not approve to pay invoice

VR Counselor: Date: