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ALL ESS ContractsALL Forms Checklists
Index
Next Page
Customized Employment Contract Forms
Employment & Retention Contract Forms
Employment Support Services Contract Forms
Job Placement Contract Forms
JOBS Contract Forms
Supported Employment Contract Forms
Individualized Placement and Supports (IPS) Services Pilot Project Contract Forms
07/01/2020
Customized Employment (Pilot Project) Forms Checklist
Customized Employment Contract Index Next Page
CE Discovery and Profile Top
Career Exploration
Internship
CE Team Meeting
Visual Resume
CE Job Development
CE Job Coaching 1
CE Job Coaching 2
CE Onsite Supports and Training
CE Maintenance
CE Extended Services for Transition
CE Employment Outcome
Legend: ® = required ® = required if applicable
07/01/2020 Page 2 Customized Employment (Pilot Project) Contract
Customized Employment (Pilot Project) Forms Checklist
CE Discovery and Profile CE Contract Index Back Next Page Top
Required Case Documentation for Payment :☐ ® ESS-C-101 — CE Invoice
☐ ® ESS-C-105 — CE Discovery Activity Log/Notes
☐ ® ESS-C-109 — CE Discovery Intake
☐ ® ESS-C-113 — CE Discovery Profile Report
☐ ® ESS-C-117 — Travel Log & Invoice (when travel is authorized)
☐ ® ESS-C-121 — CE Authorization Request Form (required unless next two planned service authorizations already received)
☐ ® ESS-C-125n — Contractor Written Justification for less than twenty-five (25) hours to complete (if applicable)
☐ ® ESS-C-129n — DRS Counselor Written Approval for less than twenty-five (25) hours (if applicable)
☐ ® ESS-C-133 — DRS Counselor Monthly Update Form(s) (required if Discovery and Profile extends beyond one month from authorization date)
Legend: ® = required ® = required if applicable
07/01/2020 Page 3 Customized Employment (Pilot Project) Contract
Customized Employment (Pilot Project) Forms Checklist
Career Exploration CE Contract Index Back Next Page Top
Required Case Documentation for Payment:☐ ® ESS-C-101 — CE Invoice (required with each month of billing)☐ ® ESS-C-117 — Travel Log & Invoice (when travel is authorized)
☐ ® ESS-C-121 — CE Authorization Request Form (required unless next two planned service authorizations already received)
☐ ® ESS-C-133 — DRS Counselor Monthly Update Form(s)
☐ ® ESS-C-137 — Plan of Exploration (E-Mail to DRS Counselor prior to implementation (maintain copy of E-Mail))
☐ ® ESS-C-139 — Situational Assessment Reports (not required by contract)
☐ ® ESS-C-140 — Career Exploration Activity Log (this form does not exist)
☐ ® ESS-C-141 — Career Exploration Report
☐ ® ESS-C-145n — DRS Counselor Response to Plan of Exploration
☐ ® ESS-C-149n — Contractor's Written Justification for completing less than three (3) different activities (if applicable)
☐ ® ESS-C-153n — DRS Counselor Written Approval for completing less than three (3) different activities (if applicable)
Legend: ® = required ® = required if applicable
07/01/2020 Page 4 Customized Employment (Pilot Project) Contract
Customized Employment (Pilot Project) Forms Checklist
Internship CE Contract Index Back Next Page Top
Required Case Documentation for Payment:☐ ® ESS-C-101 — CE Invoice (required with each month’s billing) ☐ ® ESS-C-117 — Travel Log & Invoice (when travel is authorized)
☐ ® ESS-C-121 — CE Authorization Request Form (required unless next two planned service authorizations already received)
☐ ® ESS-C-133 — DRS Counselor Monthly Update Form(s)
☐ ® ESS-C-157 — Pre-Placement Information Form (Prior to start date of internship, E-Mail to DRS Counselor, Cc ESS TA)
☐ ® ESS-C-161 — Job Analysis (Completed during the first week of internship)
☐ ® ESS-C-165 — Internship Placement Report (required at the end of the 1st month of internship)
☐ ® ESS-C-169 — Internship Time Log (required with each month of billing)
☐ ® ESS-C-173 — Team Meeting Narrative (required with final billing)
☐ ® ESS-C-177 — Placement Report (required with final billing if hired by the same employer)
☐ ® ESS-C-180 — Job Furlough Report (if applicable, E-Mail to DRS Counselor, Cc ESS TA)
☐ ® ESS-C-181 — Upon Contractor being notified of termination, complete Termination/Re-Placement Report. (E-Mail to DRS Counselor, Cc ESS TA)
☐ ® ESS-C-181 — Prior to start date of re-placement, update the above Termination/Re-Placement Report with the new job information. (E-Mail to DRS Counselor, Cc ESS TA)
☐ ® ESS-C-185 — Job Accommodation Form
☐ ® ESS-C-189 — Agreement to Report SSA Earnings (if SSA recipient)
☐ ® ESS-C-193 — SSA Earnings Report Letter (if SSA recipient)
☐ ® ESS-C-197n — Internship Agreement Documentation
Legend: ® = required ® = required if applicable
07/01/2020 Page 5 Customized Employment (Pilot Project) Contract
Customized Employment (Pilot Project) Forms Checklist
CE Team Meeting CE Contract Index Back Next Page Top
Required Case Documentation for Payment:☐ ® ESS-C-101 — CE Invoice
☐ ® ESS-C-117 — Travel Log & Invoice (when travel is authorized)
☐ ® ESS-C-121 — CE Authorization Request Form (required unless next two planned service authorizations already received)
☐ ® ESS-C-133 — DRS Counselor Monthly Update Form
☐ ® ESS-C-173 — Team Meeting Narrative
☐ ® ESS-C-201 — CE Employer Contact List
Legend: ® = required ® = required if applicable
07/01/2020 Page 6 Customized Employment (Pilot Project) Contract
Customized Employment (Pilot Project) Forms Checklist
Visual Résumé CE Contract Index Back Next Page Top
Required Case Documentation for Payment for Visual Résumé:☐ ® ESS-C-101 — CE Invoice
☐ ® ESS-C-117 — Travel Log & Invoice (when travel is authorized)
☐ ® ESS-C-121 — CE Authorization Request Form (required unless next two planned service authorizations already received)
☐ ® ESS-C-133 — DRS Counselor Monthly Update Form(s)
☐ ® ESS-C-205n — Visual Résumé (E-Mail to DRS Counselor)
☐ ® ESS-C-206n — Copy of DRS Counselor response to the visual résumé E-Mail (if received)
Legend: ® = required ® = required if applicable
07/01/2020 Page 7 Customized Employment (Pilot Project) Contract
Customized Employment (Pilot Project) Forms Checklist
Job Development CE Contract Index Back Next Page Top
Required Case Documentation for Payment for Job Development:☐ ® ESS-C-101 — CE Invoice (required Monthly for up to six (6) months)
☐ ® ESS-C-117 — Travel Log & Invoice (when travel is authorized)
☐ ® ESS-C-121 — CE Authorization Request Form (required unless next two planned service authorizations already received)
☐ ® ESS-C-133 — DRS Counselor Monthly Update Form(s)
☐ ® ESS-C-157 — Pre-Placement Information Form (Prior to start date, E-Mail to DRS Counselor, Cc ESS TA)
☐ ® ESS-C-161 — Job Analysis (completed prior to first day of employment, and required with final billing)
☐ ® ESS-C-173 — Team Meeting Narrative(s) (required every three (3) months with billing, if service extends more than three months)
☐ ® ESS-C-177 — Placement Report (required with final billing)
☐ ® ESS-C-181 — Upon Contractor being notified of termination, complete Termination/Re-Placement Report. (E-Mail to DRS Counselor, Cc ESS TA)
☐ ® ESS-C-181 — Prior to start date of re-placement, update the above Termination/Re-Placement Report with the new job information. (E-Mail to DRS Counselor, Cc ESS TA)
☐ ® ESS-C-185 — Job Accommodation Form (required with final billing)
☐ ® ESS-C-189 — Agreement to Report SSA Earnings (if SSA recipient)
☐ ® ESS-C-193 — SSA Earnings Report Letter (if SSA recipient)
☐ ® ESS-C-209 — CE Employer Needs Analysis (required with final billing)
☐ ® ESS-C-213n — O*NET median hourly wage documentation for State of Oklahoma (E-Mail to DRS Counselor, Cc ESS TA Prior to start date, if hired by contractor)
☐ ® ESS-C-217 — CE Employer Development Report (required Monthly)
Legend: ® = required ® = required if applicable
07/01/2020 Page 8 Customized Employment (Pilot Project) Contract
Customized Employment (Pilot Project) Forms Checklist
Job Coaching I (2 Months Cumulative) CE Contract Index Back Next Page Top
Required Case Documentation for Payment for 1st Month: ☐ ® ESS-C-101 — CE Invoice
☐ ® ESS-C-117 — Travel Log & Invoice (when travel is authorized)
☐ ® ESS-C-121 — CE Authorization Request Form (required unless next two planned service authorizations already received)
☐ ® ESS-C-133 — DRS Counselor Monthly Update Form(s)
☐ ® ESS-C-180 — Job Furlough Report (if applicable, E-Mail to DRS Counselor, Cc ESS TA)
☐ ® ESS-C-181 — Upon Contractor being notified of termination, complete Termination/Re-Placement Report. (E-Mail to DRS Counselor, Cc ESS TA)
☐ ® ESS-C-181 — Prior to start date of re-placement, update the above Termination/Re-Placement Report with the new job information. (E-Mail to DRS Counselor, Cc ESS TA)
☐ ® ESS-C-185 — Job Accommodation Form (if applicable)
☐ ® ESS-C-221 — CE Job Coaching Report
☐ ® ESS-C-225 — Record of Hours Worked (weeks 1 – 4)☐ ® ESS-C-229 — Natural Supports Plan
☐ ® ESS-C-233 — Employer Verification Form (signed by the employer)
Legend: ® = required ® = required if applicable
07/01/2020 Page 9 Customized Employment (Pilot Project) Contract
Customized Employment (Pilot Project) Forms Checklist
Job Coaching I (2 Months Cumulative) CE Contract Index Back Next Page Top
Required Case Documentation for Payment 2nd Month: ☐ ® ESS-C-101 — CE Invoice
☐ ® ESS-C-117 — Travel Log & Invoice (when travel is authorized)
☐ ® ESS-C-121 — CE Authorization Request Form (required unless next two planned service authorizations already received)
☐ ® ESS-C-133 — DRS Counselor Monthly Update Form(s)
☐ ® ESS-C-180 — Job Furlough Report (if applicable, E-Mail to DRS Counselor, Cc ESS TA)
☐ ® ESS-C-181 — Upon Contractor being notified of termination, complete Termination/Re-Placement Report. (E-Mail to DRS Counselor, Cc ESS TA)
☐ ® ESS-C-181 — Prior to start date of re-placement, update the above Termination/Re-Placement Report with the new job information. (E-Mail to DRS Counselor, Cc ESS TA)
☐ ® ESS-C-185 — Job Accommodation Form (only if changed)
☐ ® ESS-C-221 — CE Job Coaching Report
☐ ® ESS-C-225 — Record of Hours Worked (weeks 5 – 8) ☐ ® ESS-C-229 — Natural Supports Plan (only if updated)☐ ® ESS-C-237n — Current Pay Stub/Earnings Statement
Legend: ® = required ® = required if applicable
07/01/2020 Page 10 Customized Employment (Pilot Project) Contract
Customized Employment (Pilot Project) Forms Checklist
CE Contract Index Back Next Page Top
Job Coaching II (4 Months Cumulative)
Required Case Documentation for Payment for 1st Month:☐ ® ESS-C-101 — CE Invoice
☐ ® ESS-C-117 — Travel Log & Invoice (when travel is authorized)
☐ ® ESS-C-121 — CE Authorization Request Form (required unless next two planned service authorizations already received)
☐ ® ESS-C-133 — DRS Counselor Monthly Update Form(s)
☐ ® ESS-C-180 — Job Furlough Report (if applicable, E-Mail to DRS Counselor, Cc ESS TA)
☐ ® ESS-C-181 — Upon Contractor being notified of termination, complete Termination/Re-Placement Report. (E-Mail to DRS Counselor, Cc ESS TA)
☐ ® ESS-C-181 — Prior to start date of re-placement, update the above Termination/Re-Placement Report with the new job information. (E-Mail to DRS Counselor, Cc ESS TA)
☐ ® ESS-C-185 — Job Accommodation Form (only if updated)☐ ® ESS-C-221 — CE Job Coaching Report
☐ ® ESS-C-225 — Record of Hours Worked (weeks 9 – 12)☐ ® ESS-C-229 — Natural Supports Plan (only if updated)☐ ® ESS-C-233 — Employer Verification Form (signed by the Employer, only required when
moving to the 2nd month of CE Job Coaching II)
☐ ® ESS-C-237n — Current Pay Stub/Earnings Statement (only required when moving to CE Maintenance after one month)
Legend: ® = required ® = required if applicable
07/01/2020 Page 11 Customized Employment (Pilot Project) Contract
Customized Employment (Pilot Project) Forms Checklist
CE Contract Index Back Next Page Top
Job Coaching 2 (4 Months Cumulative)
Required Case Documentation for Payment for 2nd Month:☐ ® ESS-C-101 — CE Invoice
☐ ® ESS-C-117 — Travel Log & Invoice (when travel is authorized)
☐ ® ESS-C-121 — CE Authorization Request Form (required unless next two planned service authorizations already received)
☐ ® ESS-C-133 — DRS Counselor Monthly Update Form(s)
☐ ® ESS-C-173 — Team Meeting Narrative (if applicable)
☐ ® ESS-C-180 — Job Furlough Report (if applicable, E-Mail to DRS Counselor, Cc ESS TA)
☐ ® ESS-C-181 — Upon Contractor being notified of termination, complete Termination/Re-Placement Report. (E-Mail to DRS Counselor, Cc ESS TA)
☐ ® ESS-C-181 — Prior to start date of re-placement, update the above Termination/Re-Placement Report with the new job information. (E-Mail to DRS Counselor, Cc ESS TA)
☐ ® ESS-C-185 — Job Accommodation Form (only if updated)☐ ® ESS-C-221 — CE Job Coaching Report
☐ ® ESS-C-225 — Record of Hours Worked (weeks 13 – 16)☐ ® ESS-C-229 — Natural Supports Plan (only if updated)☐ ® ESS-C-233 — Employer Verification Form (signed by the employer)
Legend: ® = required ® = required if applicable
07/01/2020 Page 12 Customized Employment (Pilot Project) Contract
Customized Employment (Pilot Project) Forms Checklist
Onsite Supports and Training CE Contract Index Back Next Page Top
Monthly Required Case Documentation for Payment: ☐ ® ESS-C-101 — CE Invoice
☐ ® ESS-C-117 — Travel Log & Invoice (when travel is authorized)
☐ ® ESS-C-121 — CE Authorization Request Form (required unless next two planned service authorizations already received)
☐ ® ESS-C-133 — DRS Counselor Monthly Update Form(s)
☐ ® ESS-C-173 — Team Meeting Narrative(s) (submit every four months, as applicable)
☐ ® ESS-C-180 — Job Furlough Report (if applicable, E-Mail to DRS Counselor, Cc ESS TA)
☐ ® ESS-C-181 — Upon Contractor being notified of termination, complete Termination/Re-Placement Report. (E-Mail to DRS Counselor, Cc ESS TA)
☐ ® ESS-C-181 — Prior to start date of re-placement, update the above Termination/Re-Placement Report with the new job information. (E-Mail to DRS Counselor, Cc ESS TA)
☐ ® ESS-C-185 — Job Accommodation Form (if applicable)
☐ ® ESS-C-225 — Record of Hours Worked (submit Monthly beginning weeks 17 – 20; and ending weeks 73 – 76, as provided.
☐ ® ESS-C-229 — Natural Supports Plan (only if updated)
☐ ® ESS-C-233 — Employer Verification Form (signed by the employer, required at the completion of each 4 month increment of Onsite Supports and Training)
☐ ® ESS-C-241 — Onsite Supports and Training Report
Legend: ® = required ® = required if applicable
07/01/2020 Page 13 Customized Employment (Pilot Project) Contract
Customized Employment (Pilot Project) Forms Checklist
CE Maintenance CE Contract Index Back Next Page Top
Required Case Documentation for Payment:☐ ® ESS-C-101 — CE Invoice
☐ ® ESS-C-117 — Travel Log & Invoice (when travel is authorized)
☐ ® ESS-C-121 — CE Authorization Request Form (required unless next two planned service authorizations already received)
☐ ® ESS-C-133 — DRS Counselor Monthly Update Form(s)
☐ ® ESS-C-180 — Job Furlough Report (if applicable, E-Mail to DRS Counselor, Cc ESS TA)
☐ ® ESS-C-181 — Upon Contractor being notified of termination, complete Termination/Re-Placement Report. (E-Mail to DRS Counselor, Cc ESS TA)
☐ ® ESS-C-181 — Prior to start date of re-placement, update the above Termination/Re-Placement Report with the new job information. (E-Mail to DRS Counselor, Cc ESS TA)
☐ ® ESS-C-225 — Record of Hours Worked
☐ ® ESS-C-233 — Employer Verification Form (signed by the employer)
☐ ® ESS-C-245 — CE Maintenance Report
☐ ® ESS-C-249 — Employee Satisfaction Survey
☐ ® ESS-C-253 — EST Extended Services Statement
☐ ® ESS-C-257 — Natural Supports Cooperative Agreement (only when natural supports are used)
Legend: ® = required ® = required if applicable
07/01/2020 Page 14 Customized Employment (Pilot Project) Contract
Customized Employment (Pilot Project) Forms Checklist
CE Contract Index Back Next Page Top
Extended Services for Transition
MONTHLY Required Case Documentation for Payment :☐ ® ESS-C-101 — CE Invoice (required with monthly billing)
☐ ® ESS-C-117 — Travel Log & Invoice (when travel is authorized)
☐ ® ESS-C-121 — CE Authorization Request Form (required unless next planned service authorization already received)
☐ ® ESS-C-133 — DRS Counselor Monthly Update Form(s)
☐ ® ESS-C-173 — Team Meeting Narrative(s) (required at least annually during the provision of 48 months of service and at the completion of EST service)
☐ ® ESS-C-180 — Job Furlough Report (if applicable, E-Mail to DRS Counselor, Cc ESS TA)
☐ ® ESS-C-181 — Upon Contractor being notified of termination, complete Termination/Re-Placement Report. (E-Mail to DRS Counselor, Cc ESS TA)
☐ ® ESS-C-181 — Prior to start date of re-placement, update the above Termination/Re-Placement Report with the new job information. (E-Mail to DRS Counselor, Cc ESS TA)
☐ ® ESS-C-185 — Job Accommodation Form (only if updated)
☐ ® ESS-C-225 — Record of Hours Worked (submit monthly beginning weeks 17 – 20; and ending weeks 73 – 76, when working)
☐ ® ESS-C-229 — Natural Supports Plan (if applicable), only if updated
☐ ® ESS-C-233 — Employer Verification Form (signed by the employer – required at least once annually and upon completion of Onsite Supports and Training)
☐ ® ESS-C-249 — Employee Satisfaction Survey (required at least annually during the provision of up to 48 months of service and upon completion of EST service)
☐ ® ESS-C-261 — EST Extended Services Report (required at least annually during the provision of up to 48 months of service and upon completion of EST service) changed from contract wording for clarification
Legend: ® = required ® = required if applicable
07/01/2020 Page 15 Customized Employment (Pilot Project) Contract
Customized Employment (Pilot Project) Forms ChecklistCE Contract Index Back Next Page Top
CE Employment Outcome
Required Case Documentation for Payment:☐ ® ESS-C-101 — CE Invoice
☐ ® ESS-C-117 — Travel Log & Invoice (when travel is authorized)
☐ ® ESS-C-133 — DRS Counselor Monthly Update Form(s)
☐ ® ESS-C-180 — Job Furlough Report (if applicable, E-Mail to DRS Counselor, Cc ESS TA)
☐ ® ESS-C-181 — Upon Contractor being notified of termination, complete Termination/Re-Placement Report. (E-Mail to DRS Counselor, Cc ESS TA)
☐ ® ESS-C-181 — Prior to start date of re-placement, update the above Termination/Re-Placement Report with the new job information. (E-Mail to DRS Counselor, Cc ESS TA)
☐ ESS-C-185 — Job Accommodation Form (required only if updated)
☐ ® ESS-C-225 — Record of Hours Worked
☐ ® ESS-C-233 — Employer Verification Form (signed by the employer) or ☐ ® ESS-C-237n — Current Paystub/Earnings Statement
☐ ® ESS-C-249 — Employee Satisfaction Survey
☐ ® ESS-C-265 — CE Employment Outcome Report
Legend: ® = required ® = required if applicable
07/01/2020 Page 16 Customized Employment (Pilot Project) Contract
Employment & Retention Contract Forms Checklist
Employment & Retention Index Back Next Page Top
ER Assessment
ER Vocational Preparation (Optional)
ER Placement
ER 4 Week Retention
ER Employment
Legend: ® = required ® = required if applicable
07/01/2020 Page 17 Employment & Retention Contract
Employment & Retention Contract Forms Checklist
ER AS Employment & Retention Index Back Next Page Top
Required Case Documentation for Payment:☐ ® ESS-C-117 — Travel Log & Invoice (when travel is authorized)
☐ ® ESS-C-133 — DRS Counselor Monthly Update Form(s)
☐ ® ESS-C-139 — Situational Assessment Report
☐ ® ESS-C-161 — Job Analysis (if applicable)
☐ ® ESS-C-173 — Team Meeting Narrative
☐ ® ESS-C-273 — ER Authorization Request Form (required unless next two planned service authorizations already received)
☐ ® ESS-C-277 — ER Plan for Assessment ☐ ® ESS-C-281n — DRS Counselor response to Plan for Assessment
☐ ® ESS-C-285n — Electronic Résumé (E-Mail to DRS Counselor)
☐ ® ESS-C-289n — Job Description (if in-house situational assessment/s)
☐ ® ESS-C-297 — Compatibility Analysis
☐ ® ESS-C-301 — ER Post Assessment Report
☐ ® ESS-C-305n — Copies of all assessments performed
☐ ® ESS-C-309 — ER AS Milestone Report
☐ ® ESS-C-313 — ER Milestone Billing Form
☐ ® ESS-C-329 — Comprehensive Vocational Profile
Legend: ® = required ® = required if applicable
07/01/2020 Page 18 Employment & Retention Contract
Employment & Retention Contract Forms Checklist
ER VP (Optional) Employment & Retention Index Back Next Page Top
Required Case Documentation for Payment:☐ ® ESS-C-117 — Travel Log & Invoice (when travel is authorized)
☐ ® ESS-C-133 — DRS Counselor Monthly Update Form(s)
☐ ® ESS-C-273 — ER Authorization Request Form (required unless next two planned service authorizations already received)
☐ ® ESS-C-313 — ER Milestone Billing Form
☐ ® ESS-C-317n — Copies of summary pages from vocational interest inventories
☐ ® ESS-C-321 — Job Club Sign-In Sheet
☐ ® ESS-C-325 — Copy of Certificate of Completion issued to individual
Legend: ® = required ® = required if applicable
07/01/2020 Page 19 Employment & Retention Contract
Employment & Retention Contract Forms Checklist
ER PL Employment & Retention Index Back Next Page Top
Required Case Documentation for Payment:☐ ® ESS-C-117 — Travel Log & Invoice (when travel is authorized)
☐ ® ESS-C-133 — DRS Counselor Monthly Update Form(s)
☐ ® ESS-C-157 — Pre-Placement Information Form (Prior to start date, E-Mail to DRS Counselor, Cc ESS TA)
☐ ® ESS-C-161 — Job Analysis (completed before first (1st) day of work, if applicable)
☐ ® ESS-C-180 — Job Furlough Report (if applicable, E-Mail to DRS Counselor, Cc ESS TA)
☐ ® ESS-C-181 — Upon Contractor being notified of termination, complete Termination/Re-Placement Report. (E-Mail to DRS Counselor, Cc ESS TA)
☐ ® ESS-C-181 — Prior to start date of re-placement, update the above Termination/Re-Placement Report with the new job information. (E-Mail to DRS Counselor, Cc ESS TA)
☐ ® ESS-C-185 — Job Accommodation Form
☐ ® ESS-C-189 — Agreement to Report SSA Earnings (if SSA recipient)☐ ® ESS-C-193 — SSA Earnings Report Letter (if SSA recipient)☐ ® ESS-C-213n — O*NET median hourly wage documentation for the State of Oklahoma (E-
Mail to the DRS Counselor, Cc ESS TA, if applicable)
☐ ® ESS-C-273 — ER Authorization Request Form (required unless next two planned service authorizations already received)
☐ ® ESS-C-313 — ER Milestone Billing Form
☐ ® ESS-C-333 — ER PL Milestone Report
Legend: ® = required ® = required if applicable
07/01/2020 Page 20 Employment & Retention Contract
Employment & Retention Contract Forms Checklist
ER R4 (Optional) Employment & Retention Index Back Next Page Top
Required Case Documentation for Payment:☐ ® ESS-C-117 — Travel Log & Invoice (when travel is authorized)
☐ ® ESS-C-133 — DRS Counselor Monthly Update Form(s)
☐ ® ESS-C-180 — Job Furlough Report (if applicable, E-Mail to DRS Counselor, Cc ESS TA)
☐ ® ESS-C-181 — Upon Contractor being notified of termination, complete Termination/Re-Placement Report. (E-Mail to DRS Counselor, Cc ESS TA)
☐ ® ESS-C-181 — Prior to start date of re-placement, update the above Termination/Re-Placement Report with the new job information. (E-Mail to DRS Counselor, Cc ESS TA)
☐ ® ESS-C-185 — Job Accommodation Form (if applicable)
☐ ® ESS-C-225 — Record of Hours Worked
☐ ® ESS-C-233 — Employer Verification Form (Signed by Employer, if obtained)
☐ ® ESS-C-237n — Current Paystub/Earnings Statement
☐ ® ESS-C-273 — ER Authorization Request Form (required unless next planned service authorization already received)
☐ ® ESS-C-313 — ER Milestone Billing Form
☐ ® ESS-C-337 — ER R4 Milestone Report
Legend: ® = required ® = required if applicable
07/01/2020 Page 21 Employment & Retention Contract
Employment & Retention Contract Forms Checklist
ER EM Employment & Retention Index Back Next Page Top
Required Case Documentation for Payment : ☐ ® ESS-C-117 — Travel Log & Invoice (when travel is authorized)
☐ ® ESS-C-133 — DRS Counselor Monthly Update Form(s)
☐ ® ESS-C-180 — Job Furlough Report (if applicable, E-Mail to DRS Counselor, Cc ESS TA)
☐ ® ESS-C-181 — Upon Contractor being notified of termination, complete Termination/Re-Placement Report. (E-Mail to DRS Counselor, Cc ESS TA)
☐ ® ESS-C-181 — Prior to start date of re-placement, update the above Termination/Re-Placement Report with the new job information. (E-Mail to DRS Counselor, Cc ESS TA)
☐ ® ESS-C-225 — Record of Hours Worked
☐ ® ESS-C-233 — Employer Verification Form (Signed by Employer, if obtained)
☐ ® ESS-C-237n — Current Paystub/Earnings Statement
☐ ® ESS-C-249 — Employee Satisfaction Survey
☐ ® ESS-C-313 — ER Milestone Billing Form
☐ ® ESS-C-341 — ER EM Milestone Report
Legend: ® = required ® = required if applicable
07/01/2020 Page 22 Employment & Retention Contract
Employment Support Services Contract Forms Checklist
Employment Support Services Index Back Next Page Top
ESS Employment Support Assessment
ESS Support Services for Employment
Legend: ® = required ® = required if applicable
07/01/2020 Page 23 Employment Support Services Contract
Employment Support Services Contract Forms Checklist
Employment Support Assessment Employment Support Services Index Back Next Page Top
Required Case Documentation for Payment :☐ ® ESS-C-117 — Travel Log & Invoice (when travel is authorized)
☐ ® ESS-C-133 — DRS Counselor Monthly Update Form/s
☐ ® ESS-C-305n — Copies of all assessments performed
☐ ® ESS-C-345 — ESS Billing Form
☐ ® ESS-C-349 — ESS Assessment Referral
The following as requested on ESS-C-349 — ESS Assessment Referral:
☐ ® ESS-C-353-1 — ESS Assessment - Cognitive Assessment
☐ ® ESS-C-353-2 — ESS Assessment - Communication Assessment
☐ ® ESS-C-353-3 — ESS Assessment - Computer Technology Assessment
☐ ® ESS-C-353-4 — ESS Assessment - Daily Living Assessment
☐ ® ESS-C-353-5 — ESS Assessment - Housing Assessment
☐ ® ESS-C-353-6 — ESS Assessment - Mobility Assessment
☐ ® ESS-C-353-7 — ESS Assessment - Work/Training Tolerance Assessment
☐ ® ESS-C-353-8 — ESS Assessment - Transportation Assessment
☐ ® ESS-C-353-9 — ESS Assessment Summary
Legend: ® = required ® = required if applicable
07/01/2020 Page 24 Employment Support Services Contract
Employment Support Services Contract Forms Checklist
Support Services for Employment Employment Support Services Index Back Next Page Top
Required Case Documentation for Payment :☐ ® ESS-C-117 — Travel Log & Invoice (when travel is authorized)
☐ ® ESS-C-133 — DRS Counselor Monthly Update Form(s)
☐ ® ESS-C-345 — ESS Billing Form
☐ ® ESS-C-357 — ESS Training Support Plan (E-Mail to DRS Counselor)
☐ ® ESS-C-358n — Copy of Training Support Plan (E-Mail sent to the DRS Counselor)
☐ ® ESS-C-361n — Copy of DRS Counselor response (if received)
☐ ® ESS-C-365 — ESS Training Support Summary
Legend: ® = required ® = required if applicable
07/01/2020 Page 25 Employment Support Services Contract
Job Placement Contract Forms Checklist
Job Placement Index Back Next Page Top
JP Assessment
JP Placement
JP Employment
Legend: ® = required ® = required if applicable
07/01/2020 Page 26 Job Placement Contract
Job Placement Contract Forms Checklist
JP AS Job Placement Index Back Next Page Top
Required Case Documentation for Payment : ☐ ® ESS-C-117 — Travel Log & Invoice (when travel is authorized)
☐ ® ESS-C-133 — DRS Counselor Monthly Update Form(s)
☐ ® ESS-C-285n — Electronic Résumé (E-Mail to DRS Counselor)
☐ ® ESS-C-369 — JP Milestone Billing Form
☐ ® ESS-C-373 — JP AS Milestone Report
☐ ® ESS-C-377n — Assessment results including potential job matches, (if applicable)
Legend: ® = required ® = required if applicable
07/01/2020 Page 27 Job Placement Contract
Job Placement Contract Forms Checklist
JP PL Job Placement Index Back Next Page Top
Required Case Documentation for Payment : ☐ ® ESS-C-117 — Travel Log & Invoice (when travel is authorized)
☐ ® ESS-C-133 — DRS Counselor Monthly Update Form(s)
☐ ® ESS-C-157 — Pre-Placement Information Form (Prior to start date, E-Mail to DRS Counselor, Cc ESS TA)
☐ ® ESS-C-161 — Job Analysis (completed before first (1st) day of work, if applicable)
☐ ® ESS-C-180 — Job Furlough Report (if applicable, E-Mail to DRS Counselor, Cc ESS TA)
☐ ® ESS-C-181 — Upon Contractor being notified of termination, complete Termination/Re-Placement Report. (E-Mail to DRS Counselor, Cc ESS TA)
☐ ® ESS-C-181 — Prior to start date of re-placement, update the above Termination/Re-Placement Report with the new job information. (E-Mail to DRS Counselor, Cc ESS TA)
☐ ® ESS-C-185 — Job Accommodation Form
☐ ® ESS-C-189 — Agreement to Report SSA Earnings (if SSA recipient)
☐ ® ESS-C-193 — SSA Earnings Report Letter (if SSA recipient)
☐ ® ESS-C-213n — O*NET median hourly wage documentation for State of Oklahoma (E-Mail to DRS Counselor, Cc ESS TA Prior to start date, if hired by contractor)
☐ ® ESS-C-369 — JP Milestone Billing Form
☐ ® ESS-C-381 — JP PL Milestone Report
Legend: ® = required ® = required if applicable
07/01/2020 Page 28 Job Placement Contract
Job Placement Contract Forms Checklist
JP EM Job Placement Index Back Next Page Top
Required Case Documentation for Payment : ☐ ® ESS-C-117 — Travel Log & Invoice (when travel is authorized)
☐ ® ESS-C-133 — DRS Counselor Monthly Update Form(s)
☐ ® ESS-C-180 — Job Furlough Report (if applicable, E-Mail to DRS Counselor, Cc ESS TA)
☐ ® ESS-C-181 — Upon Contractor being notified of termination, complete Termination/Re-Placement Report. (E-Mail to DRS Counselor, Cc ESS TA)
☐ ® ESS-C-181 — Prior to start date of re-placement, update the above Termination/Re-Placement Report with the new job information. (E-Mail to DRS Counselor, Cc ESS TA)
☐ ® ESS-C-225 — Record of Hours Worked
☐ ® ESS-C-237n — Current Paystub/Earnings Statement
☐ ® ESS-C-249 — Employee Satisfaction Survey
☐ ® ESS-C-369 — JP Milestone Billing Form
☐ ® ESS-C-385 — JP EM Milestone Report
Legend: ® = required ® = required if applicable
07/01/2020 Page 29 Job Placement Contract
JOBS Contract Forms Checklist
JOBS Contract Index Back Next Page Top
Job Service
Legend: ® = required ® = required if applicable
07/01/2020 Page 30 JOBS Contract
JOBS Contract Forms Checklist
Job Service JOBS Contract Index Back Next Page Top
Required Case Documentation for Payment : ☐ ® ESS-C-117 — Travel Log & Invoice (when travel is authorized)
☐ ® ESS-C-133 — DRS Counselor Monthly Update Form(s)
☐ ® ESS-C-157 — Pre-Placement Information Form (Prior to start date, E-Mail to DRS Counselor, Cc ESS TA with ESS-C-285n Electronic Résumé)
☐ ® ESS-C-180 — Job Furlough Report (if applicable, E-Mail to DRS Counselor, Cc ESS TA)
☐ ® ESS-C-181 — Upon Contractor being notified of termination, complete Termination/Re-Placement Report. (E-Mail to DRS Counselor, Cc ESS TA)
☐ ® ESS-C-181 — Prior to start date of re-placement, update the above Termination/Re-Placement Report with the new job information. (E-Mail to DRS Counselor, Cc ESS TA)
☐ ® ESS-C-185 — Job Accommodation Form, (if applicable)
☐ ® ESS-C-213n — O*NET median hourly wage documentation for the State of Oklahoma (E-Mail to DRS Counselor, Cc ESS TA Prior to start date, if applicable)
☐ ® ESS-C-285n — Electronic Résumé (Prior to start date, E-Mail to DRS Counselor with ESS-C-157 — Pre-Placement Information Form)
☐ ® ESS-C-389 — JOBS 60 Day Completion Report
☒ ® ESS-C-393 — JOBS Billing Form
Legend: ® = required ® = required if applicable
07/01/2020 Page 31 JOBS Contract
Supported Employment Contract Forms Checklist
Supported Employment Index Back Next Page Top
SE AssessmentSE Vocational PreparationSE PlacementSE 4 Week RetentionSE 8 Week RetentionSE StabilizationSE Successful Employment
Legend: ® = required ® = required if applicable
07/01/2020 Page 32 Supported Employment
Supported Employment Contract Forms Checklist
SE Assessment Back Next Page TopSupported Employment Index
Required Case Documentation for Payment :☐ ® ESS-C-117 — Travel Log & Invoice (when travel is authorized)
☐ ® ESS-C-133 — DRS Counselor Monthly Update Form(s) (if more than one month since referral)
☐ ® ESS-C-139 — Situational Assessment Reports
☐ ® ESS-C-161 — Job Analysis
☐ ® ESS-C-173 — Team Meeting Narrative
☐ ® ESS-C-289n — Job Description (if in-house situational assessment/s)
☐ ® ESS-C-297 — Compatibility Analysis
☐ ® ESS-C-397 — SE Authorization Request Form (required unless next two planned service authorizations already received)
☐ ® ESS-C-401 — SE Milestone Billing Form
☐ ® ESS-C-405 — SE AS Milestone Report
☐ ® ESS-C-409 — SE Plan for Assessment
☐ ® ESS-C-413 — Highly Challenged Criteria Form was submitted to the Contractor by the DRS Counselor (if applicable)
☐ ® ESS-C-413 — Highly Challenged Criteria Form with documentation E-Mailed/faxed to DRS Counselor (if applicable)
Legend: ® = required ® = required if applicable
07/01/2020 Page 33 Supported Employment
Supported Employment Contract Forms Checklist
SE Vocational Preparation Back Next Page TopSupported Employment Index
Required Case Documentation for Payment :☐ ® ESS-C-117 — Travel Log & Invoice (when travel is authorized)
☐ ® ESS-C-133 — DRS Counselor Monthly Update Form(s) (if more than one month since referral)
☐ ® ESS-C-317n — Copies of summary pages from vocational interest inventories
☐ ® ESS-C-321 — Job Club Sign-In Sheet
☐ ® ESS-C-325 — Copy of Certificate of Completion issued to individual
☐ ® ESS-C-397 — SE Authorization Request Form (required unless next two planned service authorizations already received)
☐ ® ESS-C-401 — SE Milestone Billing Form
Legend: ® = required ® = required if applicable
07/01/2020 Page 34 Supported Employment
Supported Employment Contract Forms Checklist
SE Placement Back Next Page TopSupported Employment Index
Required Case Documentation for Payment:☐ ® ESS-C-117 — Travel Log & Invoice (when travel is authorized)
☐ ® ESS-C-133 — DRS Counselor Monthly Update Form(s) (if more than one month since referral)
☐ ® ESS-C-157 — Pre-Placement Information Form (Prior to start date, E-Mail to DRS Counselor, Cc ESS TA)
☐ ® ESS-C-161 — Job Analysis (completed before first (1st) day of work)
☐ ® ESS-C-180 — Job Furlough Report (if applicable, E-Mail to DRS Counselor, Cc ESS TA)
☐ ® ESS-C-181 — Upon Contractor being notified of termination, complete Termination/Re-Placement Report. (E-Mail to DRS Counselor, Cc ESS TA)
☐ ® ESS-C-181 — Prior to start date of re-placement, update the above Termination/Re-Placement Report with the new job information. (E-Mail to DRS Counselor, Cc ESS TA)
☐ ® ESS-C-185 — Job Accommodation Form
☐ ® ESS-C-189 — Agreement to Report SSA Earnings (if SSA recipient)
☐ ® ESS-C-193 — SSA Earnings Report Letter (if SSA recipient)
☐ ® ESS-C-213n — O*NET median hourly wage documentation for the State of Oklahoma (if applicable)
☐ ® ESS-C-397 — SE Authorization Request Form (required unless next two planned service authorizations already received)
☐ ® ESS-C-401 — SE Milestone Billing Form
☐ ® ESS-C-417 — SE PL Milestone Report
Legend: ® = required ® = required if applicable
07/01/2020 Page 35 Supported Employment
Supported Employment Contract Forms Checklist
SE R4 Back Next Page TopSupported Employment Index
Required Case Documentation for Payment:☐ ® ESS-C-117 — Travel Log & Invoice (when travel is authorized)
☐ ® ESS-C-133 — DRS Counselor Monthly Update Form
☐ ® ESS-C-173 — Team Meeting Narrative
☐ ® ESS-C-180 — Job Furlough Report (if applicable, E-Mail to DRS Counselor, Cc ESS TA)
☐ ® ESS-C-181 — Upon Contractor being notified of termination, complete Termination/Re-Placement Report. (E-Mail to DRS Counselor, Cc ESS TA)
☐ ® ESS-C-181 — Prior to start date of re-placement, update the above Termination/Re-Placement Report with the new job information. (E-Mail to DRS Counselor, Cc ESS TA)
☐ ® ESS-C-185 — Job Accommodation Form (if applicable)
☐ ® ESS-C-225 — Record of Hours Worked
☐ ® ESS-C-229 — Natural Supports Plan
☐ ® ESS-C-233 — Employer Verification (signed by the employer), if obtained
☐ ® ESS-C-237n — Current Pay Stub/Earnings Statement
☐ ® ESS-C-397 — SE Authorization Request Form (required unless next two planned service authorizations already received)
☐ ® ESS-C-401 — SE Milestone Billing Form
☐ ® ESS-C-421 — SE R4 Milestone Report
Legend: ® = required ® = required if applicable
07/01/2020 Page 36 Supported Employment
Supported Employment Contract Forms Checklist
SE R8 Back Next Page TopSupported Employment Index
Required Case Documentation for Payment:☐ ® ESS-C-117 — Travel Log & Invoice (when travel is authorized)
☐ ® ESS-C-133 — DRS Counselor Monthly Update Form
☐ ® ESS-C-180 — Job Furlough Report (if applicable, E-Mail to DRS Counselor, Cc ESS TA)
☐ ® ESS-C-181 — Upon Contractor being notified of termination, complete Termination/Re-Placement Report. (E-Mail to DRS Counselor, Cc ESS TA)
☐ ® ESS-C-181 — Prior to start date of re-placement, update the above Termination/Re-Placement Report with the new job information. (E-Mail to DRS Counselor, Cc ESS TA)
☐ ® ESS-C-185 — Job Accommodation Form (if applicable)
☐ ® ESS-C-225 — Record of Hours Worked
☐ ® ESS-C-229 — Natural Supports Plan (if applicable)
☐ ® ESS-C-233 — Employer Verification (signed by the employer)
☐ ® ESS-C-249 — Employee Satisfaction Survey
☐ ® ESS-C-397 — SE Authorization Request Form (required unless next two planned service authorizations already received)
☐ ® ESS-C-401 — SE Milestone Billing Form
☐ ® ESS-C-425 — SE R8 Milestone Report
Legend: ® = required ® = required if applicable
07/01/2020 Page 37 Supported Employment
Supported Employment Contract Forms Checklist
SE Stabilization Twelve (12) Weeks or Sixteen (16) Weeks for HCSupported Employment Index Back Next Page Top
Required Case Documentation for Payment:☐ ® ESS-C-117 — Travel Log & Invoice (when travel is authorized)
☐ ® ESS-C-133 — DRS Counselor Monthly Update Form(s)
☐ ® ESS-C-173 — Team Meeting Narrative
☐ ® ESS-C-180 — Job Furlough Report (if applicable, E-Mail to DRS Counselor, Cc ESS TA)
☐ ® ESS-C-181 — Upon Contractor being notified of termination, complete Termination/Re-Placement Report. (E-Mail to DRS Counselor, Cc ESS TA)
☐ ® ESS-C-181 — Prior to start date of re-placement, update the above Termination/Re-Placement Report with the new job information. (E-Mail to DRS Counselor, Cc ESS TA)
☐ ® ESS-C-225 — Record of Hours Worked
☐ ® ESS-C-233 — Employer Verification (signed by the employer)
☐ ® ESS-C-249 — Employee Satisfaction Survey
☐ ® ESS-C-253 — EST Extended Services Statement
☐ ® ESS-C-257 — Natural Supports Cooperative Agreement (if applicable)
☐ ® ESS-C-397 — SE Authorization Request Form (required unless next planned service authorization already received)
☐ ® ESS-C-401 — SE Milestone Billing Form
☐ ® ESS-C-429 — SE ST Milestone Report
☐ ® ESS-C-433 — SE ST HC Milestone Report (Report weeks thirteen to sixteen (13-16) if needed for highly challenged)
Legend: ® = required ® = required if applicable
07/01/2020 Page 38 Supported Employment
Supported Employment Contract Forms Checklist
SE Successful Employment Supported Employment Index Back Next Top
Required Case Documentation for Payment:☐ ® ESS-C-117 — Travel Log & Invoice (when travel is authorized)
☐ ® ESS-C-133 DRS Counselor Monthly Update Form(s)
☐ ® ESS-C-180 — Job Furlough Report (if applicable, E-Mail to DRS Counselor, Cc ESS TA)
☐ ® ESS-C-181 — Upon Contractor being notified of termination, complete Termination/Re-Placement Report. (E-Mail to DRS Counselor, Cc ESS TA)
☐ ® ESS-C-181 — Prior to start date of re-placement, update the above Termination/Re-Placement Report with the new job information. (E-Mail to DRS Counselor, Cc ESS TA)
☐ ® ESS-C-225 — Record of Hours Worked
☐ ® ESS-C-237n — Current Pay Stub/Earnings Statement
☐ ® ESS-C-249 — Employee Satisfaction Survey
☐ ® ESS-C-401 — SE Milestone Billing Form
☐ ® ESS-C-437 — SE EM Milestone Report
Top
Legend: ® = required ® = required if applicable
07/01/2020 Page 39 Supported Employment
Individualized Placement Supports (IPS) Contract Forms Index
Back Next Page Top
IPS Career Profile Milestone
IPS 15-Day Job Placement & Retention Milestone
IPS 45-Day Employment Milestone
IPS Re-placement Milestone (one time only)
IPS 90-Day Competitive Integrated Employment and Retention Milestone
07/01/2020 Page 40 Individualized Placement Supports
Individualized Placement Supports (IPS) Contract Forms Checklist
IPS Career Profile Milestone Back Next Page Top
Individualized Placement Supports Index
Required Case Documentation for Payment for IPS CP Milestone :☐ ® ESS-C-700 — IPS Milestone Billing Form
☐ ® ESS-C-705 — Career Profile
☐ ® ESS-C-710 — Educational Experience Report (when in training)
07/01/2020 Page 41 Individualized Placement Supports
Individualized Placement Supports (IPS) Contract Forms Checklist
IPS 15-Day Job Placement & Retention Milestone Back Next Page TopIndividualized Placement Supports Index
Required Case Documentation for Payment for IPS 15-Day JP & R Milestone :☐ ® ESS-C-185 — Job Accommodation Form
☐ ® ESS-C-225 — Record of Hours Worked or related Contractor Form/Report
☐ ® ESS-C-700 — IPS Milestone Billing Form
☐ ® ESS-C-705 — Career Profile (when updated)
☐ ® ESS-C-710 — Educational Experience Report (when in training)☐ ® ESS-C-715 — Job Search Plan (e-mailed to the DRS Counselor when completed)
☐ ® ESS-C-720 — Job Start Report
☐ ® ESS-C-725 — Employer Contact Log(s)
☐ ® ESS-C-730 — Job Support Plan
☐ ® ESS-C-735 — Job End Report (if applicable)
07/01/2020 Page 42 Individualized Placement Supports
Individualized Placement Supports (IPS) Contract Forms Checklist
IPS 45-Day Employment Milestone Back Next Page TopIndividualized Placement Supports Index
Required Case Documentation for Payment for IPS 45-Day Employment Milestone :☐ ® ESS-C-225 — Record of Hours Worked or related Contractor Form/Report
☐ ® ESS-C-700 — IPS Milestone Billing Form
☐ ® ESS-C-705 — Career Profile (when updated)
☐ ® ESS-C-710 — Educational Experience Report (when in training)☐ ® ESS-C-720 — Job Start Report (if applicable)
☐ ® ESS-C-725 — Employer Contact Log(s)
☐ ® ESS-C-735 — Job End Report (if applicable)
07/01/2020 Page 43 Individualized Placement Supports
Individualized Placement Supports (IPS) Contract Forms Checklist
IPS Re-placement Milestone (one time only) Back Next Page TopIndividualized Placement Supports Index
Required Case Documentation for Payment for IPS Re-placement Milestone :☐ ® ESS-C-185 — Job Accommodation Form ☐ ® ESS-C-225 — Record of Hours Worked or related Contractor Form/Report
☐ ® ESS-C-700 — IPS Milestone Billing Form
☐ ® ESS-C-705 — Career Profile (when updated)
☐ ® ESS-C-710 — Educational Experience Report (when in training)☐ ® ESS-C-720 — Job Start Report (if applicable)
☐ ® ESS-C-725 — Employer Contact Log(s)
☐ ® ESS-C-735 — Job End Report (if applicable)
07/01/2020 Page 44 Individualized Placement Supports
Individualized Placement Supports (IPS) Contract Forms Checklist
IPS 90-Day Competitive Integrated Employment and Retention MilestoneIndividualized Placement Supports Index Back Top
Required Case Documentation for Payment for IPS 90-Day Competitive Integrated Employment and Retention Milestone:
☐ ® ESS-C-185 — Job Accommodation Form (if updated)☐ ® ESS-C-225 — Record of Hours Worked or related Contractor Form/Report
☐ ® ESS-C-237n — Paystub and/or Earnings Statement ☐ ® ESS-C-700 — IPS Milestone Billing Form
☐ ® ESS-C-705 — Career Profile (when updated)
☐ ® ESS-C-710 — Educational Experience Report (when in training)☐ ® ESS-C-720 — Job Start Report (if applicable)
☐ ® ESS-C-725 — Employer Contact Log(s) ☐ ® ESS-C-730 — Job Support Plan
☐ ® ESS-C-735 — Job End Report (if applicable)
Top
07/01/2020 Page 45 Individualized Placement Supports