Fillable Employed for 90 days Group per Individual SUPPORTED (California)

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Employed for 90 days Group per Individual SUPPORTED (California)

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STATE OF CALIFORNIA DEPARTMENT OF REHABILITATION
SUPPORTED EMPLOYMENT - MONTHLY JOB COACH REPORT Page 1 of 2
DR384 (Rev. 02/08)
Consumer:
Report Month/Year:
UCI#:
Birthdate:
DOR Counselor:
SE Service Provider:
DOR District:
Employer/Site Name & Address:
Job Coach:
Job Coach Phone:
Job Title:
Individual
Group
Wage:
per
Start Date:
Employed for 90 days
Work Schedule (indicate work hours; example: 9am-2pm):
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Total hours consumer worked
On-site Coaching
Off-site Coaching (Individual Placement (IP) only)
Total hours coached (excludes Job Coach Travel and Lunch Break Support)
Percent of Intervention (POI) (IP only) (Divide total hours coached this
month by the total hours consumer worked this month and multiply by 100.)
%
Job Coach Travel (JCT) hours (IP only)
Lunch Break Support (LBS) hours (Group only)
Total hours billed (includes JCT and LBS, cannot exceed hours authorized)
Total hours authorized
Date services authorized through
Check boxes for any areas of unsatisfactory performance (and note other issues below):
Work Habits Work Performance Interpersonal Skills
Attendance/Punctuality Understanding of Job Tasks Supervisor
Following Procedures Accuracy/Quality Co-workers
Cooperation Work Pace Customer/Public
Taking Initiative Focus/Concentration Job Coach
Grooming/Hygiene Passing Probation
Areas checked must be addressed in a proposed plan to improve performance
See attached DR384A Plan to Improve Performance. See other issues below.
Other issues related to job performance/termination: (attach additional sheets, as needed)
Consumer comments/view of progress: (attach additional sheets, as needed)
Termination Date:
Form Completed By:
Phone:
DOR Use Only: Account Tech Initials Invoice Processed Date:
Other:
NOTICE: This is confidential information from the records of the California Department of Rehabilitation. State and federal law and
departmental regulations prohibit you from making any further disclosure of this information without the informed, written consent of the
person to whom this information pertains.
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0
STATE OF CALIFORNIA DEPARTMENT OF REHABILITATION
SUPPORTED EMPLOYMENT - MONTHLY JOB COACH REPORT Page 2 of 2
DR384 (Rev. 02/08)
Consumer:
Report Month/Year:
Key: TYPES OF JOB COACH INTERVENTION - Must be specifically authorized. See RAM31510.
Off-site Coaching: For
Individual Placement (IP) only, job support services provided as Training (T),
Advocacy (A) or Job Loss Intervention (JLI). (Fill in “Description of Specific Off-Site Coaching
Activities” below with abbreviation (T, A, or JLI) and details (e.g. “T - social skills”))
Job Coach Travel (JCT): For IP only, travel time to the consumer's worksite (one way only, note total
on page 1).
Lunch Break Support (LBS): For consumers in
Group Placement (GP) only, assistance with health/
safety or developing natural supports (e.g. coworker relationships) (note total on page 1).
Job Coaching Hours Date Consumer
Work Hours
On Site
Off Site (IP)
Description of Specific Off-Site
Coaching Activities (IP Only)
JCT Hours
(IP Only)
LBS Hours
(GP Only)
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Total
Distribution: DOR Counselor (via email or fax, see DR381) DOR District Office (with Invoice)
Regional Center Service Coordinator (via email / fax when percentage of intervention is 30% or less)
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Employed for 90 days Group per Individual SUPPORTED (California)

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Completed 13 June 2021

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