14. AGENCY’S ACCEPTANCE OF PLANTwo
Guys From Alaska in a One-Stop
Alaska
Division of Vocational Rehabilitation
Individualized Plan for Employment
1.
Name:_______________________________________________
2.
Date
this plan begins: ____________Date this plan ends:_____________
3.
My
disability causes the following employment barriers:
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
4.
I have other employment barriers not related to my disability including:
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
5.
Description of the job or other work setting I
seek:________________________________________________________
6.
These are my personal qualities, skills, abilities and strengths that support
this goal: ________________________________________________
_______________________________________________________
_______________________________________________________
7.
Here are my solutions to overcoming the barriers listed
above:_________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
8.
This is how I want my rehabilitation counselor to be involved with me throughout
this plan:
Encourage
me throughout this plan.
Help
me work out any problems that might come up.
Provide
on-going guidance and counseling.
Other:_____________________________________________
9.
These services will help me overcome my employment barriers so I can work:
a.
Service: _______________________________________________________
Name
of service provider chosen: ___________________________________
How
I chose this person or organization:
_____________________________________________________________________________________________
Cost
of service or product: $________________________________________
Who
pays for it? __________________________________________________
Amount
DVR pays: $ ______________________________________________
Date
service begins: ________________ Date service ends:______________
b.
Service: _______________________________________________________
Name
of service provider chosen: ___________________________________
How
I chose this person or organization: _________________________________
Cost
of service or product: $________________________________________
Who
pays for it? __________________________________________________
Amount
DVR pays: $ ______________________________________________
Date
service begins:________________ Date service ends:
_______________________________________________________________
c.
Service: _______________________________________________________
Name
of service provider chosen: ___________________________________
How
I chose this person or organization:
______________________________________________________________________________________________________________
Cost
of service or product: $________________________________________
Who
pays for it? __________________________________________________
Amount
DVR pays: $ ______________________________________________
Date
service begins: ________________ Date service ends:______________
d.
Service: _______________________________________________________
Name
of service provider chosen: ___________________________________
How
I chose this person or organization:
______________________________________________________________________________________________________________
Cost
of service or product: $________________________________________
Who
pays for it? __________________________________________________
Amount
DVR pays: $ ______________________________________________
Date
service begins: _________________Date service ends: _____________
e.
Service: _______________________________________________________
Name
of service provider chosen: ___________________________________
How
I chose this person or organization:
______________________________________________________________________________________________________________
Cost
of service or product: $________________________________________
Who
pays for it? __________________________________________________
Amount
DVR pays: $ ______________________________________________
Date
service begins: _______________ Date service ends: ______________
10.
This is how I will know if I am making progress toward my job goal:
____________________________________________________________
____________________________________________________________
11.
These are the services I might need at the end of this plan so I can remain
employed: _______________________________________________________
_______________________________________________________
·
Complete it
to the best of my ability.
·
Notify my
counselor immediately if I need to change this plan.
·
Review this
plan with my DVR counselor at least once a year to decide whether I need any
changes made. This is in addition to meeting regularly to review my progress.
·
Go to work
at the completion of this plan.
·
Apply for
other resources through the following organizations to help pay for these
services:______________________________________________
· Other: __________________________________________________
·
My right to
choose how to develop this plan.
·
Availability
of assistance in developing this plan.
·
An
explanation of the agency’s guidelines & criteria regarding who pays for
the services I need.
·
Evaluating
my ability to help pay for these services.
·
Helping me
understand my rights as a participant and how to resolve any problems if they
arise.
·
The Client
Assistance Program and how I can contact their representative.
·
My right to
appeal any action made by D.V.R. with which I disagree. I understand I must make
my dissatisfaction known to D.V.R. within 30 days of the action in question.
13.
AGREEMENT AND AUTHORIZATION OF SERVICES
I picked the above employment goal, the services I need and the individuals or organizations who will provide these to me. By signing this plan, I intend to go to work. I authorize the Division of Vocational Rehabilitation to proceed with these services as funds become available.
_______________________________________________________
Participant’s
Signature / date
_______________________________________________________
Guardian or
Representative’s Signature as needed
date
14. AGENCY’S ACCEPTANCE OF PLAN
_______________________________________________________
Qualified Rehabilitation
Counselor’s Signature
date
_______________________________________________________
Regional Manager’s
Signature as needed
date
15. PARTNER AGENCY
AGREEMENT:
_______________________________________________________
Signature of
representative
date
Name
of partner agency:___________________________________________
AMENDMENT
1.
Name:
_____________________________________________________
2. Date this change
begins: __________ Date this change ends: __________
3. I need to make the
following changes to my plan for employment:
_______________________________________________________
_______________________________________________________
_______________________________________________________
4. I need the following
additional service(s):
a.
Service: _______________________________________________________
Name
of service provider chosen: ___________________________________
How
I chose this person or organization:
______________________________________________________________________________________________________________
Cost
of service or product: $________________________________________
Who
pays for it? __________________________________________________
Amount
DVR pays: $ ______________________________________________
Date
service begins: _______________ Date service ends: ______________
b.
Service: _______________________________________________________
Name
of service provider chosen: ___________________________________
How
I chose this person or organization:
______________________________________________________________________________________________________________
Cost
of service or product: $ _______________________________________
Who
pays for it? _________________________________________________
Amount
DVR pays: $ ______________________________________________
Date
service begins: _______________ Date service ends: ______________
c.
Service: _______________________________________________________
Name
of service provider chosen: ___________________________________
How
I chose this person or organization:
______________________________________________________________________________________________________________
Cost
of service or product: $ _______________________________________
Who
pays for it? _________________________________________________
Amount
DVR pays: $______________________________________________
Date
service begins: ________________Date service ends: _____________
Yes, I need additional services listed at the end of
this plan.
No, I do not need additional services beyond what I
noted above.
5. AGREEMENT AND
AUTHORIZATION OF SERVICES
I chose the
above employment goal, the services I need and the individuals or organizations
who will provide these to me. By signing this plan, I intend to go to work. I
authorize the Division of Vocational Rehabilitation to make these changes to my
plan, as funds become available.
_______________________________________________________
Participant’s
Signature / date
6.
AGENCY’S ACCEPTANCE OF AMENDMENT
_______________________________________________________
Qualified
Rehabilitation Counselor’s Signature / date
_______________________________________________________
Regional
Manager’s Signature as needed / date
Supplemental Sheet
Name:
_______________________________________________________
My
Disability causes the following employment barriers:
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
I
have other employment barriers not related to my disability including:
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
Here
are my solutions to overcoming the barriers listed above:
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
SUPPLEMENTAL SHEET
Service: _______________________________________________________
Name
of service provider chosen: ___________________________________
How
I chose this person or organization:
______________________________________________________________________________________________________________
Cost
of service or product: $________________________________________
Who
pays for it? __________________________________________________
Amount
DVR pays: $ ______________________________________________
Date
service begins:______________ Date service ends: ________________
Service:
_______________________________________________________
Name
of service provider chosen: ___________________________________
How
I chose this person or organization:
______________________________________________________________________________________________________________
Cost
of service or product: $________________________________________
Who
pays for it? __________________________________________________
Amount
DVR pays: $ ______________________________________________
Date
service begins: ________________ Date service ends: _____________
Service:
_______________________________________________________
Name
of service provider chosen: ___________________________________
How
I chose this person or organization:
______________________________________________________________________________________________________________
Cost
of service or product: $________________________________________
Who
pays for it? __________________________________________________
SUPPLEMENTAL SHEET CONTINUED
Amount
DVR pays: $ ______________________________________________
Date
service begins: ________________Date service ends: ______________
Service: _______________________________________________________
Name
of service provider chosen: ___________________________________
How
I chose this person or organization:
______________________________________________________________________________________________________________
Cost
of service or product: $________________________________________
Who
pays for it? __________________________________________________
Amount
DVR pays: $ ______________________________________________
Date
service begins: ________________ Date
service ends: _____________
Service: _______________________________________________________
Name
of service provider chosen: ___________________________________
How
I chose this person or organization:
______________________________________________________________________________________________________________
Cost
of service or product: $________________________________________
Who
pays for it? __________________________________________________
Amount
DVR pays: $ ______________________________________________
Date
service begins: ________________ Date
service ends: _____________