VR2954 (02/23) Comprehensive Assessment for ILS-OIB Program Page 1 of 5

Texas Workforce Commission Vocational Rehabilitation Services

Comprehensive Assessment for ILS-OIB Program

General Information

Customer:

Assessment completed by (if completed by a vendor):

Assessment beginning date:

Assessment ending date:

Independent Living and Communication Skills

Assess all the following areas in terms of current training needs using the following codes:

Y – yes, training needed N – no, training not needed

Assessment Area Code

• Preparing meals and maintaining kitchen safety

• Measuring and pouring liquids and dry ingredients

• Using appliances in the home

• Eating skills

• Performing household chores

• Sewing and crafts

• Providing dependent care (children, spouse, other family member, etc.)

• Personal grooming

• Dressing (clothing and shoe identification, laundry skills, etc.)

• Accessing printed materials

• Writing and calendar skills

• Using the telephone

• Time telling

• Identifying money

• Managing finances

• Organizing and labeling

• Using braille

Does the customer have a computer? Yes No

Does the customer need information on a computer issue? Yes No

If yes, what information is needed?

Does the customer need to be assessed for a magnifier or closed-circuit TV? Yes No

EXAMPLE

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Does the customer need a low-vision evaluation? Yes No

Comments, if any:

Managing Secondary Disabilities

List secondary disabilities:

Does the customer have a hearing loss? Yes No

Does the customer need a deafblind evaluation? Yes No

Does the customer need a hearing evaluation and/or hearing aids? Yes No

Does the customer need diabetes education? Yes No

Assess all the following areas in terms of current training needs using the following codes:

Y – yes, training needed N – no, training not needed

Assessment Area Code

• Managing diabetes (blood sugar levels, insulin administration, medications, meals, etc.)

• Managing other health conditions (high blood pressure, congestive heart failure, etc.)

• Managing medications

Comments:

Travel and Transportation

Assess all the following areas in terms of current training needs using the following codes:

Y – yes, training needed N – no, training not needed

Assessment Area Code

• Mobility in and around the home

• Detecting steps or drop-offs

• Maintaining balance when walking

• Using public or private transportation

• Traveling outside the home

What are the customer’s goals for travel-related training and orientation and mobility (O&M) training?

Is an O&M evaluation recommended? Yes No

Does the customer want to participate in O&M training? Yes No

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Support System

Who provides the customer’s primary (natural) support system?

What community resources does the customer already use?

Are any other referrals needed? Yes No

If yes, list the referrals:

Quality of Life

Does the customer participate in leisure, volunteer, or recreation activities? Yes No

Would the customer like to be more active? Yes No

If yes, how?

What training would improve the customer’s quality of life?

Adjustment to Blindness

Is the customer coping with his or her vision loss? Yes No

Is the customer ready or motivated to participate in services? Yes No

Does the customer advocate for himself or herself and express needs? Yes No

Is the customer using adaptive techniques? Yes No

If so, what adaptations are being used?

Is the customer at risk of going to a more dependent living environment (for example, an assisted living facility or a nursing home) without the provision of IL services? Yes No

Summary of Recommendations and Justification for Equipment

Make additional comments here, and list any additional services, equipment, or supplies that the customer needs:

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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.

Typed or printed name:

Signature: (See VR-SFP 3 on Signatures)

X

Date signed:

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.

Director Typed or Printed name:

Director 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

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

Printed name of VR staff member making verification:

1. Date: 2. Date:

VR Counselor Review

Verified the trainer recorded the specific training services he or she provided to the customer and documented the customer’s progress he or she observed on this form.

Yes No

Verified that there was discussion with customer on managing secondary disabilities. Yes No

Verified that Travel and Transportation activities were assessed with customer including customer’s goals for travel-related training.

Yes No

Verified that customer has a natural support system and is familiar with other community resources.

Yes No

Verified that there was discussion regarding customer’s leisure, volunteer, and/or recreation activities.

Yes No

Verified that customer’s adjustment to blindness was addressed. Yes No

Verified that additional services, equipment, or supplies were discussed (if appropriate). 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 satisfaction with services received.

Approve to pay invoice Do not approve to pay invoice

VR Counselor: Date: