Description of job duties and responsibilities: Kelly is responsible for inspecting vehicles for damage and recording findings so that repairs can be made; estimating costs of vehicle repair, troubleshooting fuel, ignition, and emissions control systems; repairing, overhaling, and adjusting brake systems, testing electronic computer components in vehicles; following checklists to ensure all important parts are examined; conferring with customers to obtain descriptions of vehicle problems and to discuss repairs.

How does the employer classify the position (check all that apply):

|_| Permanent |_| Temp-to-hire |_| Seasonal |_| Full-time |_| Part-time |_| As needed (PRN)

|_| Contract Employee that will receive an IRS1099 |_| Other: Describe:

Work Schedule: Record the start time, end time of work day and total hours worked daily below.

Employer defined work week (for example, Sunday – Saturday):

Weekday:

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Start Time:

7:30 am

End Time:

3:30 pm

Total Hours:

Average hours customer works weekly: 40

Do you expect the customer’s hours to change weekly? |_| Yes |_| No

Hourly wage: $8.34

Gross weekly earnings: $333.60

The customer is paid:

|_| Weekly |_| Bi-Weekly (every two weeks)

|_| Monthly (one time each month) |_| Bi-Monthly (twice each month)

|_| Other:

Service Delivery Information at Placement—5th day

Record the first 5 days the customer worked performing work duties and hours worked each day.

Day 1

Date: 2 July 19

Hours Worked: 8

Comments: In-processing/training

Day 2

Date: 3 July 19

Hours Worked: 8

Comments: Orientation to store/garage area

Day 3

Date: 4 July 19

Hours Worked: 5

Comments: Helped stock for Holiday prep

Day 4

Date: 5 July 19

Hours Worked: 8

Comments: Side-by-side training with co-worker

Day 5

Date: 6 July 19

Hours Worked: 8

Comments: Certifications/training on equipment

Employment schedule and work hours was verified through:

|_| Employer contact |_| Customer contact |_| Pay Stub |_| Observing the customer at work

|_| Other. Describe:

Describe the role(s) of the Job Placement Specialist in assisting the customer with obtaining and maintaining the job.

I assisted Kelly with filling out the Personal Employment Data Sheet, writing a resume and edited the resume with him. He ws trained on filling out job applications appropriately, I helped him identify job references and trained him on expected written correspondence, we completed interview training and recorded four mock interviews with Kelly. The JPS trained Kelly on appropriate responses to pre-employment testing, assisted Kelly in learning job search strategies and completed side-by-side job search with him. He was trained on job acceptance and preparing for the first day of work. Also, I assisted Kelly in networking with employers and how to follow-up with employers after he submits his application and/or resume. This assistance helped him in obtaining a job at Pep Boys.

Describe any steps taken to customize the position for the customer to meet the needs of the customer and the business. (for example, blending job descriptions)

I assisted Kelly in negotiating his employment hours, so that he was able to start at 7:30am and end at 3:30pm, which allowed him enough time to get to late afternoon medical appointments. This assistance allows Kelly to manage his disability so that he is able to maintain his job. Kelly reported being satisfied with the first five days of his new job.

Describe all accommodations, compensatory techniques, and special training needs identified or established to increase the customer’s performance in the work setting: (environmental changes, assistive technology devices, or work process)

Kelly and I discussed his accommodation needs, and he was trained on appropriate ways to request accommodations in the workplace. Kelly was able to successfully request and gain the following accommodations at Pep Boys: ear plugs to block out startling noises, extra 5 minute break each day to take medication if needed, and access to drinking water to avoid dehydration (medication side effects). He has been offered a set schedule with Monday and Sundays off.

Describe any consultations made with the business.

I visited Kelly on his first day of work and consulted with his employer to ensure that Kelly was in a supportive environment. Kelly's manager, Leon, stated that he was excited to hire Kelly and ensured us that Kelly would have access to ear plugs, extra breaks to take medications, and drinking water as needed.

Service Delivery Information at Placement, 45th day- Benchmark B

The customer has been employed and worked at least 45 days |_| Yes |_| No |_| N/A

Employment was verified through:

|_| Employer contact |_| Observing the customer at work |_| Customer contact

|_| Other: Describe:

Describe all accommodations, compensatory techniques, and special training needs identified or established at the worksite:

Describe how the customer has adjusted to the job. Include all issues or concerns and how they were addressed by the provider, employer, and customer:

Record a summary of the customer’s performance related to the job’s essential and nonessential responsibilities:

Describe any consultations made with the business:

Service Delivery Information at Placement, 90th day- Benchmark C

The customer has been employed and worked at least 90 days |_| Yes |_| No |_| N/A

Employment was verified through:

|_| Employer contact |_| Observing the customer at work |_| Customer contact

|_| Other: Describe:

Describe all accommodations, compensatory techniques, and special training needs identified or established at the worksite:

Describe how the customer has adjusted to the job. Include all issues or concerns and how they were addressed by the provider, employer, and customer:

Record a summary of the customer’s performance related to the job’s essential and nonessential responsibilities:

Describe any consultations made with the business:

Visits with the Customer

Instructions:

Record a brief summary of the visits after the first 5 days of the customer’s employment. Must have two visits as required in the outcomes for payment in the VR-SFP.

Date:

Summary of visit:

Date:

Summary of visit:

Date:

Summary of visit:

Date:

Summary of visit:

Date:

Summary of visit:

Date:

Summary of visit:

Date:

Summary of visit:

Date:

Summary of visit:

Date:

Summary of visit:

Date:

Summary of visit:

Date:

Summary of visit:

Date:

Summary of visit:

Additional Comments

Additional comments, if any:

Signatures

Instructions: New original signatures must be added each time the form is submitted. Indicate below the reason the form is being submitted.

For: |_| Original Planning Meeting |_| Updated Planning Meeting: Date:

|_| Benchmark A Reporting Period |_| Benchmark B Reporting Period

|_| Benchmark C Reporting Period |_| Other, describe:

Customer Signature

By signing below, I, the customer or authorized representative, agree with the Employment Conditions and Employment Goal recorded on this Placement Plan Report- Part 2 during the Job Placement Planning Meeting and the information recorded within the report above. If you are not satisfied, do not sign. Contact your VR counselor.

Customer’s signature:

Kelly Robinson

Date: 7 July 20198

Customer’s legally authorized representative’s signature, if any:

Date:

VR Counselor Signature (only required at the Placement Planning Meeting(s))

By signing below, I, the customer’s Vocational Rehabilitation Counselor agree with the Employment Conditions, Employment Goal and Premium service recorded on this Placement Plan Report- Part 2 during the Job Placement Planning Meeting.

VR Counselor’s signature:

Date:

Provider Qualifications

Type of Provider: |_| Traditional-bilateral contractor |_| Transition Educator |_| Non-traditional

Traditional-bilateral contractor must complete the provider qualification section below. This section is not applicable to Transition Educator and Non-traditional providers.

Qualifications

Proof of Qualification

Verified by TWS-VRS

Specify UNTWISE Credential:

Job Placement Specialist

UNTWISE Credential Number: swilson17

if no, |_| VR3490-Waiver Proof Attached

|_| Yes |_| No |_| N/A

Specify UNTWISE Endorsement:

|_| N/A

UNTWISE Endorsement Number:

|_| Yes |_| No |_| N/A

Select: |_| RID |_| BID

|_| SLIPI |_| N/A

RID/BID/SLIPI Number:

|_| Proof Attached

|_| Yes |_| No |_| N/A

Other:

Number: |_| Proof Attached

|_| Yes |_| No |_| N/A

Job Placement Specialist Signature (Required for all providers)

By signing below, I, the Job Placement Specialist, certify that:

For Placement Planning Meeting(s)

· I am in agreement with the Employment Conditions, Employment Goal and Premium service recorded on this Placement Plan Report- Part 2 during the Job Placement Planning Meeting.

For Benchmarks Status Reports submitted at completion of Benchmarks A, B and C

· the above dates, times, and services are accurate;

· all Outcomes Required for Payment as described in the TWC VR Standards for Provider and Service Authorization(s) were met;

· I personally documented the services and information described above on this form;

· the customer’s and/or customer’s legally authorized representative’s signature on this form was obtained on the date stated in the date field of the form;

· I handwrote my signature and the date below; and

· I maintain the staff qualifications required for a Job Placement Specialist as described in the TWC VR Standards for Providers or Service Authorization .

Job Placement Specialist typed name:

Steven Wilson

Job Placement Specialist signature:

X Steven Wilson

Date:

7 July 2019

Director Credentials and Signature- Not required for Job Placement Meeting

Required for Traditional-Bilateral Contractors

By signing below, I, the Director, certify that:

· I handwrote my signature and the date below; and

· I ensure that the staff meets the qualifications and met the requirements in the Standards for Providers when delivering the service and;

· I maintain the staff qualifications, including the UNTWISE credential, required for a Director, as described in Standards for Providers and/or Service Authorization.

Qualifications

Proof of Qualification

Verified by TWS-VRS

Specify UNTWISE Credential:

Director

UNTWISE Credential Number: pbrunson99

if no, |_| VR3490-Waiver Proof Attached

|_| Yes |_| No |_| N/A

Director’s typed name:

Paula Brunson

Director’s signature:

Paula Brunson