FIELD ENTRY TYPE INFORMATION DATE NON-EDITABLE Field is calculated based on information entered in the report form. Providers may not edit this field. JOB TASKS (1 – 10) NON-EDITABLE Field is calculated based on information entered in the report form. Providers may not edit this field. NARRATIVE IS REQUIRED FOR ANY METRICS NOT MET ("-"), OPTIONAL FOR METRICS THAT ARE MET ("+")ENCOURAGED FOR METRICS THAT ARE MET ("+") TEXT Enter an explanation of why the Individual did not meet a specific indicator, what interventions the Provider Staff used to address the issue, and outcome of interventions. FIELD ENTRY TYPE INFORMATION PROVIDER'S COMMENTS (INCLUDES PERFORMANCE OBSERVATIONS, CONCERNS, INCIDENTS, INTERVENTION TECHNIQUES, & RECOMMENDATIONS FOR NEXT STEPS) TEXT Summary of the Providers assessment of the Individual to include comments on the Individual’s overall performance, specific issues and/or concerns, specific interventions used by the Job Coach, and recommendations for next steps. If Provider recommends continuation of service there should be information on what the Individual still needs to work on to be competitive with specific intervention techniques and benchmarks. INDIVIDUAL'S COMMENTS TEXT Summary of how the Individual feels that they performed during the service. Summary should be in the Individual’s own words; however, Provider Staff may have to ask clarifying questions. One word or simple phrases, e.g. “I did good.” are not acceptable. EMPLOYER'S COMMENTS TEXT Summary of the Employer’s assessment of the Individual including any areas that they feel the Individual still needs to work on in order to be competitive. DATE SUMMER YOUTH WORK EXPERIENCE ONLY SUMMARY OF EDUCATIONAL TOPICS 06/05/17 Session included discussions on appropriate work place behavior. Participants were divided into small groups and given role playing scenarios. One Participant would enact the scenario and the other Participants would point out what was appropriate and inappropriate work place behaviors. Once the groups were done as a scenarios the group gathered to discuss how Participants could have handled situations differently and turned inappropriate behaviors into appropriate ones. Noah participated in the scenarios, made comments during discussion, and was respectful of other Participants ideas. FIELD ENTRY TYPE INFORMATION DATE DATE FIELD MM/DD/YY Enter the date that the service took place. SUMMER YOUTH WORK EXPERIENCE ONLY SUMMARY OF EDUCATIONAL TOPICS TEXT Enter a summary of the educational topic covered that date and specific comments on Individual’s participation.
and/or VR Contractor. VR Staff and/or VR Contractors will have five (5) business days to review the resume/mock application and provide feedback to the Provider. Sample Job Development Plan will be included in the VR Forms folder available in the Provider Section of OOD’s website (www.ood.ohio.gov). GENERAL INFORMATION FIELD ENTRY TYPE INFORMATION PROVIDER NAME TEXT Enter the name of the Provider, as it appears on VR Original Authorization & Billing JOB DEVELOPER(S) NAME(S) TEXT Enter the full name, first and last, and initials of the Direct Staff who provided the service. JOB SEEKER NAME TEXT Enter the full name, first and last, of the Individual who received the service. COUNSELOR/CONTRACTOR NAME TEXT Enter the full name of the VR Counselor or VR Contractor assigned to manage services. The name can be located in the right-mid section of the VR Original Authorization & Billing EMPLOYMENT NEEDS FIELD ENTRY TYPE INFORMATION EMPLOYMENT GOAL TEXT Enter the Employment Goal as identified on the Referral to Facility. Providers may not pursue job leads outside the Employment Goal area unless the VR Staff and/or VR Contractor amend the IPE and provide a written notification to the Provider. WAGE GOAL TEXT Enter the specific wages that the Job Seeker has indicated as a requirement for a successful placement. Providers may not pursue Employment Goals that are below this wage threshold. HOURS GOAL TEXT Enter the specific number of hours that the Job Seeker has indicated as a requirement for a successful placement. Providers may not pursue Employment Goals that are below this number of hours.
HOW TO ADDRESS SPECIFIC BARRIERS E.G. CRIMINAL HISTORY, GAPS IN EMPLOYMENT, REASONABLE ACCOMMODATION, ETC.) should include a summary of instructional techniques, an evaluation of the Job Seeker’s progress, potential concerns/barriers, and recommendations. SUMMARY OF INSTRUCTION ON HOW TO IDENTIFY POTENTIAL JOB LEADS (E.G. NETWORKING, NEWSPAPERS, ELECTRONIC JOB BOARDS, TELEPHONE BOOKS, ETC.) TEXT Enter a summary of the instruction on how the Job Seeker was taught to identify potential job leads. Providers should include a summary of instructional techniques and evaluation of Job Seeker’s progress. SOCIAL MEDIA DISCUSSION (SUMMARY & DATE) TEXT Enter the date of the discussion of how social media can impact the job search and discussion on how Job Seekers can reduce any potential adverse impact. MOCK INTERVIEW (SUMMARY & DATE) TEXT Enter the date of and summary of the Job Seeker’s performance during their mock interview. The mock interview should take place after the Job Seeker has received their Job Seeking Skills Training. RESPONSIBILITIES FIELD ENTRY TYPE INFORMATION JOB DEVELOPER RESPONSIBILITIES TEXT Enter a summary of the Job Developer’s responsibilities during the job search to make sure that services progress. JOB SEEKER RESPONSIBILITIES (E.G. JOB SEEKER WILL IDENTIFY THREE POTENTIAL EMPLOYERS PER WEEK, ETC.) TEXT Enter a summary of the Job Seeker’s responsibilities, including any “homework assignments” during the job search to make sure that services progress. SIGNATURES FILL IN Signatures must be original signatures, e.g. “wet ink” or image captured through a signature pad. Signatures may not be stored for future use. JOB DEVELOPMENT – EMPLOYMENT VERIFICATION
3 How to write a resume and cover letter 4 How to dress and appearance for interviews 5 How to interview for a job (e.g. 1:1, panel, telephone interview; how to address employment gals, reasonable accommodations, legal histories, etc.) 6 How to follow up after an interview (e.g. thank you notes, follow up calls, etc.) 7 Mock Interview 8 Impact of and how to manage social media and profiles 9 Ohio Means Jobs Registration 10/02/17 Individual has his login name/password. He demonstrated how to log into OMJ. He was able to navigate independently to the job leads area. 10 Other FIELD ENTRY TYPE INFORMATION DATE DATE FIELD MM/DD/YY Enter the date that the Individual mastered the Task and could complete it independently, or with the minimum level of supported required. INDIVIDUAL'S SELF-EVALUATION OF PERFORMANCE TEXT Enter the Individual’s self-evaluation of how they feel that they are doing in the specific area, including their comfort level in performing the task on their own. should be in the Individual’s own words; however, Provider Staff may have to ask clarifying questions. One word or simple phrases, e.g. “I did well.” are not acceptable. DATE START TIME END TIME UNITS SAM Level # OF INDIVIDUALS TASK TYPE OF CONTACT CONTACTS & ACTIVITY REPORT STAFF INITIALS 10/02/17 9:00 10:00 10 1 9 Face/Face Job Coach and Individual registered with Ohio Means Jobs. Individual will come back on 10/05 for a mock interview with Job Coaches Supervisor. MEB
10/05/17 1:00 2:00 10 1 5, 7 Face/Face Job Coach met with Individual to review interview skills. Individual participated in a mock interview with Job Coaches Supervisor. Job Coach reviewed the results with Individual. He did well with questions. Needed to take some time before answering to make answer was complete. He asked questions of Interviewer. MEB EJD FIELD ENTRY TYPE INFORMATION DATE DATE FIELD MM/DD/YY Enter the date that the service took place. Date will also auto-populate the Job Task Section. (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 NON-EDITABLE 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 authorized SAM Level for the service. # INDIVIDUALS DROP DOWN Enter the number of Individuals that received the service. If an Individual service enter “1” if a Group service enter a number between “2” and “4.” (REQUIRED FIELD) TASK TEXT Enter the number of the Task, as defined in previous table, associated with the purpose of the meeting, e.g. Ohio Means Jobs registration. If multiple Tasks are worked on during the meeting enter the number of all Tasks separated by commas. CONTACT TYPE DROP DOWN Enter the method of contact, options include: Email Face/Face Internet Telephone Text Other CONTACTS & ACTIVITY REPORT TEXT Enter a brief description of the contact. Information should include who was present, what was reviewed, any homework assignments, date/time of next meeting, etc. STAFF INITIALS TEXT Enter the initials of the Provider Staff who provided direct service to the Individual on the date.
PROVIDERS RECOMMENDATION & SUMMARY TEXT Discussion of progress with current benchmarks and recommendations for further services. Providers should be specific on what still needs to be accomplished, how it will be measured, and an estimated amount of time needed to accomplish the goal. WORK INCENTIVES PLAN INVOICE SECTION SERVICE DESCRIPTION INVOICE TOTAL $0.00 FIELD ENTRY TYPE INFORMATION SERVICE DESCRIPTION (UOS SERVICES) DROP DOWN Use this field for “Work Incentives Plan” or “Work Incentives - Credential”. If the Bilingual Supplement has been approved and authorized for the case select the “Bilingual Work Incentives Plan” or “Bilingual Work Incentives – Credential” option. This field will load the associated rates, individual and/or group, as applicable. BENEFITS SUMMARY BENEFIT PROGRAM BENEFIT AMOUNT VERIFIED BY WHOM & HOW SOCIAL SECURITY DISABILITY INSURANCE (SSDI) $540.00 BPQY from Social Security Administration SUPPLEMENTAL SECURITY INCOME (SSI) $200.00 BPQY from Social Security Administration MEDICAL BENEFIT 1 (MEDICARE) MEDICAL BENEFIT 2 (MEDICAID) Traditional Medicaid (e.g. not MBIPWD) Telephone contact with Defiance County Jobs & Family Service. HOUSING BENEFIT BENEFIT 1 BENEFIT 2 BENEFIT 3 BENEFIT 4 BENEFIT 5
DATE START TIME END TIME UNITS SAM Level SUMMARY OF ISSUE(S)/CONCERN(S) CONTACTS & SUMMARY OF STEPS TAKEN TO RESOLVE ISSUE(S)/CONCERN(S) STAFF INITIALS 0 0 FIELD ENTRY TYPE INFORMATION DATE DATE FIELD MM/DD/YY Enter the date that the service took place. Date will also auto-populate the Job Task Section. (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 NON-EDITABLE 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 authorized SAM Level for the service. SUMMARY OF ISSUE(S)/CONCERN(S) TEXT Enter a summary of the issue that was worked on that specific date. CONTACTS & SUMMARY OF STEPS TAKEN TO RESOLVE ISSUE(S)/CONCERN(S) TEXT Enter documentation of the type of contact or what actions were taken to resolve the issue on that specific date. STAFF INTIALS TEXT Enter the initials of the Provider Staff who provided direct service to the Individual on the date. INTERPRETING SPECIAL INSTRUCTIONS Due to the nature of the service, e.g. taking place in the community at different locations and needing the form to be signed, Interpreters can print off copies and hand write entries. Participants may have forms from various Interpreters if multiple staff were used to serve the individual throughout the month. Interpreters should bill all service at the end of the month or at the end of the billing cycle as defined on the Original VR Authorization & Billing (OOD-0020). INVOICE SECTION SERVICE DESCRIPTION (UOS) TOTAL $0.00 SERVICE AREA MODIFIER TOTAL $0.00
DATE START TIME MEAL PERIOD (IN MINUTES) END TIME CROSSES OVER MIDNIGHT? (YES OR NO) UNITS OF SERVICE (UOS) FIELD ENTRY TYPE INFORMATION DATE TEXT Enter the date that the service took place. Date will also auto-populate the Job Task Section. (REQUIRED FIELD) START TIME TEXT Enter the time that the actual service started, not the scheduled start time. (REQUIRED FIELD) MEAL PERIOD (IN MINUTES) TEXT Enter the meal period in minutes. For adults working over six (6) hours or minors working more than five (5) hours they must be provided a thirty (30) minute unpaid meal period. No service should take place during the meal period. END TIME TEXT Enter the time that the actual service ended, not the scheduled end time. (REQUIRED FIELD) CROSSES OVER MIDNIGHT? (YES OR NO) TEXT Enter “YES” here if the shift crosses over midnight, if it does not then leave this field blank. UNITS OF SERVICE (UOS) NON-EDITABLE Field is calculated based on information entered in the report form. Providers may not edit this field. TRANSPORTATION INVOICE SECTION Service End Date Service Description TRANSPORTATION INVOICE TOTAL $0.00