Page of DIVISION OF VOCATIONAL REHABILITATION (DVR) INDEPENDENT LIVING (IL) SERVICE PROVIDER AFP NUMBER PRE-EMPLOYMENT TRANSITION SERVICES (PRE-ETS) Service Delivery Outcome Plan: Pre-ETS IL Skills Training DVR CUSTOMER IL CONTRACTOR IL REPRESENTATIVE’S NAME SERVICE DELIVERY STAFFING INTERVALS From: To: NUMBER EXPECTED OUTCOME PARTY RESPONSIBLE PURCHASE AND PAYMENT CRITERIA COST ($) Pre-Employment Transition Services IL Skills Training activities MAXIMUM TOTAL OUTCOME FEE: $ are intended to help a student gain independent living skills as Fee per hour is $72.00 for up to hours. listed below. Outcome fee paid to Contractor upon receipt of invoice and outcomes achieved as described in IL Provider Student training areas may include: the Service Delivery Outcome Report (SDOR). Student Use of transportation services; Decision-making; VRC Fee is based on direct student activities, and Money management; does not include report writing time. Use of communication access services; Organizational abilities; SDOR must be written directly to the student, Social and interpersonal relationships; and provided to both the student and DVR Time management; VRC. Accessing community resources & benefit programs; Self-care; Report must include: Self-protection; IL Provider representative name; Attendant management. Dates and hours of all activities; Student First Name Specific IL Skills Training goals for Evidence of student skill gains in identified IL Provider include: training areas Student Specific recommendations for further VRC student exploration and experience. Travel time at a fixed rate of $35 per hour in $ quarter-hour increments if service delivery occurs more than fifty (50) miles from the contractor’s nearest staffed office location. Student Student will participate in all IL Skills Training activities, and will attend all scheduled meetings. CUSTOMER / GUARDIAN SIGNATURE DATE IL SIGNATURE DATE DVR SIGNATURE DATE TOTAL $ Signature by each indicates agreement to the contents of this plan.
DIVISION OF VOCATIONAL REHABILITATION (DVR) INDEPENDENT LIVING (IL) SERVICE PROVIDER PRE-EMPLOYMENT TRANSITION SERVICES (PRE-ETS) Service Delivery Outcome Plan: Pre-ETS IL Skills Training Page of AFP NUMBER DVR CUSTOMER IL CONTRACTOR IL REPRESENTATIVE’S NAME SERVICE DELIVERY From: To: STAFFING INTERVALS NUMBER EXPECTED OUTCOME PARTY RESPONSIBLE PURCHASE AND PAYMENT CRITERIA COST ($) Pre-Employment Transition Services IL Skills Training activities are intended to help a student gain independent living skills as listed below. MAXIMUM TOTAL OUTCOME FEE: Fee per hour is $72.00 for up to hours. Outcome fee paid to Contractor upon receipt of invoice and outcomes achieved as described in the Service Delivery Outcome Report (SDOR). Fee is based on direct student activities, and does not include report writing time. SDOR must be written directly to the student, and provided to both the student and DVR VRC. Report must include: IL Provider representative name; Dates and hours of all activities; Evidence of student skill gains in identified training areas Specific recommendations for further student exploration and experience. $ Student training areas may include: Use of transportation services; Decision-making; Money management; Use of communication access services; Organizational abilities; Social and interpersonal relationships; Time management; Accessing community resources & benefit programs; Self-care; Self-protection; Attendant management. IL Provider Student VRC Specific IL Skills Training goals for Student First Name include: IL Provider Student VRC Travel time at a fixed rate of $35 per hour in quarter-hour increments if service delivery occurs more than fifty (50) miles from the contractor’s nearest staffed office location. $ Student will participate in all IL Skills Training activities, and will attend all scheduled meetings. Student CUSTOMER / GUARDIAN SIGNATURE DATE IL SIGNATURE DATE DVR SIGNATURE DATE TOTAL $ Signature by each indicates agreement to the contents of this plan.