DARS2873,InitialPlacementReport.doc

Division for Blind Services Consumer Services Report: Initial Placement Report General Information Consumer: Provider: VR counselor: Date hired: EAS specialist: Job title: Service authorization number: Anticipated number of hours worked per week: Anticipated gross earnings per week: Employers name: Employers address: Employers telephone: Supervisors name: Supervisors title: Supervisors telephone: Job Placement Report Narrative report describing the services provided to the consumer and detailing how the services provided assisted the consumer in obtaining employment. Questions Answer Yes or No to each of the following questions. 1. Is this job consistent with the consumers interests and abilities? 2. Are the consumers wages equal to or above the current minimum wage? 3. Is the consumers job placement in an integrated setting within an organization or business that is not owned, operated, controlled, or otherwise governed by the provider? Signatures Consumer: X Date: Provider: X Date: Original: VR Counselor This is the end of the form. Press Ctrl + Home to return to the top or Shift + Tab to move backwards. DARS2873 (04/09) A+ Initial Placement Report Page 2 of 2 DARS2873 (04/09) A+ Page 1 of 2