ESBD_520882_1779973905884_Attachment 03-VR2894 Orientation and Mobility Assessment.pdf

VR2894 (02/23) Customer Services Report: Orientation and Mobility (O&M) Assessment Page 1 of 4

Texas Workforce Commission

Vocational Rehabilitation Services

Customer Services Report:

Orientation and Mobility (O&M) Assessment

General Information

Provider’s name: Service authorization number:

Counselor’s/ ILS-OIB Worker’s name: Caseload number:

Customer’s name:

Street address (include suite number, if applicable):

City: State: ZIP code:

Assessment

Date(s) of assessment: Total number of assessment hours:

Total number of anticipated training hours being recommended:

If O&M skills training is recommended, enter the anticipated date training will start:

If O&M skills training is recommended, enter the anticipated date training will end:

Is the customer in agreement with the training recommendations outlined below (explain)?

Assessment Training

For each assessment area below,

• show whether training is recommended (R), not recommended (NR), or not applicable (NA);

• show number of recommended nonvisual training hours; and

• provide a detailed explanation of circumstances and observations that support the recommendation.

Assessment area Number of training hours recommended

Why is training recommended or not?

Basic cane skills including

• open palm grip

• pencil grip

• walking in step

• touch and drag/two-point touch

• stairs

• picking up dropped objects

• cane storage (including vehicles)

• seating

• entering and exiting doors

• introduction to sidewalk travel, driveways and curb travel

SAMPLE

VR2894 (02/23) Customer Services Report: Orientation and Mobility (O&M) Assessment Page 2 of 4

Assessment area Number of training hours recommended Why is training recommended or not?

Indoor skills including

• straight line travel

• indoor numbering systems

• orientation

• problem solving

• stairs, escalators, and elevators

• locating objectives in unfamiliar places

• finding intersecting hallways

• soliciting information

• malls, grocery stores, small shops, bus and train stations, etc.

Outdoor skills including

• address system

• sun cues

• traffic

• orientation

• problem solving

• soliciting information

• parking lots

• transportations systems such as buses, paratransit, and communicating with drivers

Intersection skills including

• approaching

• analyzing

• alignment

• lights

• non-lights

• actuated

• automatic

• crossing

• crowns

• challenging traffic (heavy turn lanes, light traffic at busy intersections, night time)

• correcting veering

Extra skills including

• college campus

• rural travel

• airport, train, and bus terminals

• others, as needed

Additional Comments

Height of customer:

Height of rigid cane used for training:

Describe any travel aids the customer currently uses:

VR2894 (02/23) Customer Services Report: Orientation and Mobility (O&M) Assessment Page 3 of 4

Any additional comments or requests for support. Include any travel aids customer uses or may benefit from using:

Indicate the anticipated number of training hours per week or month (explain if less than two hours per week):

Summary:

Signatures

Orientation and Mobility Specialist Signature (Required for all providers)

By signing below, I, the Orientation and Mobility Specialist, certify that:

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

• I personally provided all services and documented all information described on this form;

• all Outcomes Require for Payment, as described in the TWC VR Standards for Provider and Service Authorization(s) were met;

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

• I maintain the staff qualifications required for the service provided as described in the TWC VR Standards for Providers or Service Authorization .

Typed or printed of name:

Signature: (See VR-SFP 3 on Signatures)

X

Date Signed:

Director

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:

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

VR2894 (02/23) Customer Services Report: Orientation and Mobility (O&M) Assessment Page 4 of 4

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 anticipated period for recommended training is identified (beginning and ending dates).

Yes No

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 that recommendations for training have been identified. Yes No

Verified that the number of recommended training hours for each area and the total number of training hours are identified.

Yes No

Verified that the height of the rigid cane that is most appropriate for the customer (using the measurement between the customer’s chin and the nose when standing up) has been identified.

Yes No

Verified that a description of all travel aids the customer uses or would benefit from using has been identified.

Yes No

By typing or printing your name, the VRC verifies:

• 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:

Original of this form goes to VR Counselor or ILS-OIB Worker.