STAFF Date Start Time End Time Units SAM MEETING LOCATION INDIVIDUAL's SIGNATURE INITIALS 0 0 FIELD ENTRY INFORMATION TYPE DATE FIELD Enter the date that the service took place. DATE MM/DD/YY (REQUIRED FIELD) Enter the time that the actual service started, not the TIME FIELD START TIME scheduled start time. AM/PM (REQUIRED FIELD) Enter the time that the actual service ended, not the TIME FIELD scheduled end time. END TIME AM/PM (REQUIRED FIELD) Field is calculated based on information entered in the UNITS report form. Providers may not edit this field. Enter the SAM Level if VR Counselor or VR SAM LEVEL DROP DOWN Contractor has pre-authorized SAM Level for the service. Enter the name of the location where the interpreting took place, e.g. if at a business enter ABC Placements, MEETING LOCATION TEXT Defiance, OH. Enter the signature of the person receiving the service. INDIVIDUAL’S SIGNATURE If the Individual is unable to sign then the Job TEXT Developer/Job Coach, VR Counselor/VR Contractor, may sign to document that the service has been provided. Enter the initials of the Provider Staff (Interpreter) who STAFF INTIALS TEXT provided direct service to the Individual on the date. VOCATIONAL TRAINING STIPEND DATE START TIME MEAL PERIOD (IN MINUTES) END TIME DAILY UNITS OF SERVICE (UOS) FIELD ENTRY INFORMATION TYPE Enter the date that the service took place. DATE TEXT (REQUIRED FIELD)
Date Start Time End Time Units SAM MEETING LOCATION INDIVIDUAL's SIGNATURE STAFF INITIALS 0 0 FIELD ENTRY TYPE INFORMATION DATE DATE FIELD MM/DD/YY Enter the date that the service took place. (REQUIRED FIELD) START TIME TIME FIELD AM/PM Enter the time that the actual service started, not the scheduled start time. (REQUIRED FIELD) END TIME TIME FIELD AM/PM Enter the time that the actual service ended, not the scheduled end time. (REQUIRED FIELD) UNITS Field is calculated based on information entered in the report form. Providers may not edit this field. SAM LEVEL DROP DOWN Enter the SAM Level if VR Counselor or VR Contractor has pre-authorized SAM Level for the service. MEETING LOCATION TEXT Enter the name of the location where the interpreting took place, e.g. if at a business enter ABC Placements, Defiance, OH. INDIVIDUAL’S SIGNATURE TEXT Enter the signature of the person receiving the service. If the Individual is unable to sign then the Job Developer/Job Coach, VR Counselor/VR Contractor, may sign to document that the service has been provided. STAFF INTIALS TEXT Enter the initials of the Provider Staff (Interpreter) who provided direct service to the Individual on the date. VOCATIONAL TRAINING STIPEND DATE START TIME MEAL PERIOD (IN MINUTES) END TIME DAILY UNITS OF SERVICE (UOS) FIELD ENTRY TYPE INFORMATION DATE TEXT Enter the date that the service took place. (REQUIRED FIELD)
VR%20Provider%20Manual%20-%20Effective%20010118.docx