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 Self-Advocacy Training DVR CUSTOMER IL CONTRACTOR IL REPRESENTATIVE’S NAME SERVICE DELIVERY DATES STAFFING INTERVALS From: To: NUMBER EXPECTED OUTCOME RESPONSIBLE PURCHASE AND PAYMENT CRITERIA COST ($) Pre-Employment Transition Services IL Self-Advocacy Training MAXIMUM TOTAL OUTCOME FEE: $ activities are intended to help a student gain self-advocacy Fee per hour is $72.00 for up to hours. skills as specified below. Outcome fee paid to Contractor upon receipt of invoice and outcomes achieved as described in Student training areas may include: IL Provider the Service Delivery Outcome Report (SDOR). Problem-solving strategies Student Assertiveness training VRC Fee is on direct student activities, and Strategies for exercising civil rights does not include report writing time. Self-determination strategies SDOR must be written directly to the student, and provided to both the student and DVR IL Provider Student First Name Specific Self-Advocacy training goals for VRC. Student include: Report must include: VRC 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 $ 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 Self-Advocacy Training activities, and will attend all scheduled meetings. CUSTOMER / GUARDIAN SIGNATURE DATE IL SIGNATURE DATE DVR SIGNATURE DATE TOTAL $ Signature by each party 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 Self-Advocacy Training Page of AFP NUMBER DVR CUSTOMER IL CONTRACTOR IL REPRESENTATIVE’S NAME SERVICE DELIVERY DATES From: To: STAFFING INTERVALS NUMBER EXPECTED OUTCOME RESPONSIBLE PURCHASE AND PAYMENT CRITERIA COST ($) Pre-Employment Transition Services IL Self-Advocacy Training activities are intended to help a student gain self-advocacy skills as specified 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 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: Problem-solving strategies Assertiveness training Strategies for exercising civil rights Self-determination strategies IL Provider Student VRC Specific Self-Advocacy 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 Self-Advocacy Training activities, and will attend all scheduled meetings. Student CUSTOMER / GUARDIAN SIGNATURE DATE IL SIGNATURE DATE DVR SIGNATURE DATE TOTAL $ Signature by each party indicates agreement to the contents of this plan.
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