DARS1635,WorkExperienceReport-TexasDepartmentofAssistive.docVIP

Department of Assistive and Rehabilitative Services Work Experience Report Follow the instructions below when completing this form. Complete the form electronically (on the computer), answering all questions. Complete one form for each staff person working with the consumer. The work experience specialist will record an answer to each question as it relates to the services provided. Write narrative summaries in paragraph form in clear, descriptive English indicating how and when you collected the information in the narrative summaries. Review the form carefully and leave no blanks. Enter “N/A” if not applicable. Make certain that all standards have been met before submitting this form with an invoice for payment. Obtain signatures and submit. Signature must be obtained at each submission. Note: The provider collects the information and completes this form except those sections indicated for “DARS use only.” This form is completed at Placement and at completion of each monthly Work Experience Report. Form Completed For: Work experience—volunteer Work experience—internship Work experience—temporary paid work Start date of services included in report: End date of services included in report: Work experience report completed for: Placement Monthly report Other: Consumer Identification Information Consumer’s name: Consumer Case ID: Consumer’s date of birth: Service authorization (SA) number: Consumer’s Work Experience Information Company name: Street address (include suite number, if any): City: State: ZIP code: Main phone number: () Supervisor’s phone number: (). Consumer’s supervisor’s name: Supervisor’s job title: Supervisor’s email address: In the spaces below, enter X to select the best methods and times to contact the supervisor: Phone Email Monday–Friday Weekends Morning Noon to 5 p.m. After 5 p.m. Other: Start date of the Work Experience: Projected end date of the Work Experience: Con