ESBD_520882_1779973928236_Attachment 04-VR2896 Orientation and Mobility Training.pdf

VR2896 (09/23) Customer Services Report: Orientation & Mobility Training Page 1 of 5

Texas Workforce Commission Vocational Rehabilitation Services

Customer Services Report: Orientation & Mobility (O&M) Training

General Information

Provider’s name: Service authorization number:

Counselor’s / OIB Worker’s name:

Customer’s name: Customer’s Case ID:

Total training hours approved at assessment:

Total training hours provided to date:

Training hours provided this month:

Training hours requested for next service authorization:

Training

For each of the skills area trained, include the date of lesson, location, hours and a brief description of the lesson provided.

Basic Cane Skills area Date of lesson

Location Hours Brief description

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

Other, please specify

Basic cane skills training hours recommended:

Hours completed for the month.

SAMPLE

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Indoor Skills Area Date of lesson

Location Hours Brief description

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 sores, small shops, bus and train stations, etc.

Indoor skills training hours recommended:

Hours completed for the month:

Outdoor Skills Area Date of lesson

Location Hours Brief description

Address system

Sun cues

Traffic

Orientation

Problem solving

Soliciting information

Parking lots

Transportation systems such as buses, paratransit, and communicating with drivers

Outdoor skills training hours recommended:

Intersection Skills area lesson

Location Hours Brief description

Approaching

Analyzing

Alignment

Lights

Nonlights

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Actuated

Automatic

Crossing

Crowns

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

Correcting veering

Intersection skills training hours recommended:

Extra Skills Area lesson

Location Hours Brief description

College campus

Rural travel

Airport, train, and bus terminals

Others as needed, please specify

Extra skills training hours recommended:

Additional Comments

Height of customer:

Height of cane used for training:

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

Certification

I certify that all lessons for VR or OIB customers were conducted per SFP 5.4.1: Orientation and Mobility Training Service Description.

Give exact dates of lessons that did not meet the standards, and attach a copy of the written approval sent by the customer’s counselor/OIB worker.

Provider Signatures

Orientation and Mobility Specialist Signature (Required for all providers)

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By signing below, I 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 Orientation and Mobility Specialist 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 (only required for Traditional-Bilateral Contractors) 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/OIB Worker)

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 the number of training hours provided in each training area. Yes No

Verified that group training was provided to a maximum of three customers. Yes No

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

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Printed name of VR staff member making verification:

1. Date: 2. Date:

VR Counselor/OIB Worker Review

Verified that the detailed narrative of each skills area addressed during the reporting period and the training location for each lesson and a detailed explanation of anticipated training for the upcoming month is completed.

Yes No

Verified that any deviation from assessment recommendations is explained. Yes No

Verified that a detailed narrative of cumulative progress is included if training is completed.

Yes No

By typing or printing your name, the VRC/OIB Worker 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 satisfaction with services received.

Approve to pay invoice Do not approve to pay invoice

VR Counselor/OIB Worker: Date: