The University of the State of New York

THE STATE EDUCATION DEPARTMENT
Office of Vocational and Educational Services for Individuals with Disabilities (VESID)

 

Supported Employment

 

Consumer Monthly Progress Report for

 

 

 

 

 

 

 

Month Year

 

  

 

DISTRICT OFFICE NAME

 

 

VR COUNSELOR NAME

 

 

 
VENDOR ID Number (from authorization)

 

 

 

 

 

 

VENDOR NAME
CONSUMER NAME Last First Middle Initial
VESID ID NUMBER (from authorization)

 

 

 

 

 

 

 

SOCIAL SECURITY NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

DATE OF BIRTH

 

 

 

 

 

 

 

 

 

 

Month Day Year

DISABILITY

(Check one only)

q
TBI

q
Physical
Disability

q
MR

q
Mental Illness (including substance abuse)

q
LD/DD
Non MR

q
Deaf

q
Blind

 

 

STABILIZATION ACHIEVED DATE

 

 

 

 

 

 

 

 

 

 

Month Day Year

(Justify below)

90 DAY STABILIZATION ACHIEVED DATE

 

 

 

 

 

 

 

 

 

 

Month Day Year

DATE OF RE-ENTRY TO INTENSIVE SERVICES

 

 

 

 

 

 

 

 

 

 

Month Day Year

PROGRAM TERMINATION

DATE

 

 

 

 

 

 

 

 

 

 

Month Day Year

SERVICE INFORMATION

Service

Category:

q
Consumer has not entered program

q
Individual

Assessment

q
Initial Service Plan

q
Progress Toward Current Goals

q
Focus of Extended Services Plan

q

Services interrupted
 

(Identify services received, barriers addressed and/or ongoing issues to resolve. If additional services are needed, a justification is required. If a recommendation for stabilization is made a justification is required. Attach additional pages if needed. See provider guidelines for more information.)



 

 

 

 

 

qJob Development Contact(s) Attached q Worksite information Attached qWaiver Request(s) Attached

 

 

CONSUMER NAME: VESID ID NUMBER: REPORT MONTH:  

 

Month Year

 

VENDOR NAME: VENDOR ID NUMBER:

 

 

STABILIZATION ACHIEVED DATE:  

 

 

 

 

 

 

 

 

 

 

Month Day Year

 VRC NAME: ____________________________________

 


TO BE COMPLETED BY VENDOR

 

TO BE COMPLETED BY DISTRICT OFFICE
  AV # From Authorization Start Date of Monthly Intensive Svc. End Date of Monthly Intensive Svc.

Hours Currently Billed

Hours to Cancel

Hours Vouchered

Hours Cancelled
AV# 1              
566X            
567X            
568X          
569X              

TOTAL

              
AV# 2              
566X            
567X            
568X          
569X              
TOTAL              
AV# 3              
566X            
567X            
568X          
569X              
TOTAL              

 

Reminder: If additional hours of service are needed contact the VESID Counselor immediately.

 
For Programmatic Purposes Only:

TOTAL HOURS: PRE-EMPLOYMENT:___________________ ON-SITE:___________________ OFF-SITE: ___________________

I hereby certify that the information contained herein is valid and accurate to the best of my knowledge:
 

__________________________________________ ________________ ________________________________

Signature of Person Completing Form (Required) Date Title

_______________________________________________ __________________ ___________________________________

Name (Please Print) Phone Number E-Mail Address

DISTRICT OFFICE USE ONLY
Detailed intensive review conducted: q Hours Appear Reasonable: Yes q No q Initials: Date:
  Voucher/Cancel Done By: (name) Date:

 

 

 

CONSUMER NAME: VESID ID NUMBER: REPORT MONTH:  

 

Month Year

 

VENDOR NAME: VENDOR ID NUMBER:

 

Job Development Contacts (Attach additional pages if needed)

 

 

Date of Contact Employer Name Name of Person Contacted

 
Outcome

 

 

 

 

 

 

Date of Contact Employer Name Name of Person Contacted

 
Outcome

 

 

 

 

 

 

Date of Contact Employer Name Name of Person Contacted

 
Outcome

 

 

Date of Contact Employer Name Name of Person Contacted

 
Outcome

 

 

Date of Contact Employer Name Name of Person Contacted

 
Outcome

 

 

Date of Contact Employer Name Name of Person Contacted

 
Outcome

 

 

CONSUMER NAME: VESID ID NUMBER: REPORT MONTH:  

Month Year
VENDOR NAME: VENDOR ID NUMBER:

 

Worksite Information (Note changes only, attach additional pages if needed)

PLACEMENT DATE

 

 

 

 

 

 

 

 

 

 

Month Day Year

 EMPLOYER NAME

DATE LEFT JOB

 

 

 

 

 

 

 

 

 

 

Month Day Year

 EMPLOYER ADDRESS Street City State Zip Code + Zip4
CONTACT NAME CONTACT JOB TITLE


 

 CONTACT PHONE NUMBER

( ) -
CONSUMER JOB TITLE DOT CODE (9 digit) RECEIVES HEALTH INSURANCE THROUGH EMPLOYMENT?

qYes qNo
HOURLY RATE HOURS WORKED PER WEEK

(If less than 20, see page 5)

 IF NOT MAKING COMPETITIVE WAGE, IS WORKING TOWARDS COMPETITIVE WAGE? qYes qNo
JOB DUTIES

 
 

EMPLOYMENT MODEL

(check one)

q
Individual Placement

q
Enclave

q
Mobile Crew

q
Affirmative

Business

q
Transitional Employment for Mental Illness

q
Other

 

Employer satisfied with consumer performance? qYes qNo Consumer satisfied with employer / employment? qYes qNo

Include documentation in the consumer file.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CONSUMER NAME: _____________________ VESID ID NUMBER:

 

 

 

 

 

 

 

 

 

 REPORT MONTH:

 

 

 

 

 

 

 

Month Year

 

 

 
VENDOR NAME: VENDOR ID NUMBER:

WAIVER REQUEST / APPROVAL

Less than 20 Hours – Fewer than 20 hours of employment per week by the time of transition to extended services. Attach additional pages if needed.
 

 

Justification/Rationale (required)

 

 

 

 

 

 

To be completed by VESID/CBVH staff only:
 

Waiver Approved: qYes qNo If no, enter reason _______________________________________
 

Name _____________________________________ Date ____________________

 

Off-site Service - Based on consumer needs, twice monthly contact will be conducted off-site. Attach additional pages if needed.
 

 

Justification/Rationale (required)

 

 

 

 

 

 

To be completed by VESID/CBVH staff only:
 

Waiver Approved: qYes qNo If no, enter reason _______________________________________
 

Name _____________________________________ Date ____________________

 

On-site intervention required for more than 18 months – More than 18 months of intensive services are needed to achieve the employment outcome once placement in a job occurs (the 18-month maximum is the cumulative total for the life of the current case regardless of the number of job placements). Attach additional pages if needed.
 

 

Justification/Rationale (required)

 

 

 

 

 

 

To be completed by VESID/CBVH staff only:
 

Waiver Approved: qYes qNo If no, enter reason _______________________________________
 

Name _____________________________________ Date ____________________