On form provided by DVR. DUE 15 th of each month following the billing (service) period. Submitted with invoice for payment 3
Billing and Payment Invoice – State Form A-19 – Payable upon: Proper completion of A-19 Monthly report. 4
Billing and Payment Must Describe and Document to DSHS’s Satisfaction: – A description of the work performed – Activities accomplished – Progress of the project – Fees 5
Delay or Non-Payment Insufficient documentation Delay in the receipt of A-19 and Reports 6
Definition - Youth – Individuals up to age 24 – But not exceeding age 26 for individuals requiring additional time for transitioning. 7
1. Youth Individuals with disabilities served during the month The total number of Youth served who have a CSR (Consumer Service Record) and are listed at least once under a, b, and c. 8
a. Individual and Systems Advocacy 9 The total number of Youth served, who have a CSR, where this service was provided.
“Individual Advocacy”means 10 Assisting a person who feels they have been discriminated against and resolving their complaint with training on self- empowerment and responsibility. This may include discrimination in services, employment, housing, healthcare, transportation, recreation, or any other aspect of a person’s life. The focus is on teaching the individual so they may advocate for themselves in the future.
“Systems Advocacy” 11 Assisting individuals or groups to advocate for the improvement and/or enforcement of laws, regulations, and program services specific to protecting the civil and human rights of all individuals.
12 Process Have a process in place to identify which individuals received Individual or Systems Advocacy associated with the Youth contract. Have a process in place to compile that information for reporting.
b. Peer Counseling 13 The total number of Youth served, who have a CSR, where this service was provided.
“Peer Counseling” means 14 Pairing individuals with disabilities, who have previously received training to provide assistance to other individuals with disabilities. This support service can be one-on-one or in groups. The purpose is to identify barriers to independent living and how to overcome or eliminate those barriers.
15 Training Requirements Have a policy in place that identifies the training requirements that qualifies individuals to perform Peer Counseling.
16 Process Have a process in place to identify which individuals that received Peer Counseling are associated with the Youth contract. Have a process in place to compile that information for reporting.
c. IL Skills Training 17 The total number of Youth served, who have a CSR, for whom this service was provided
“IL Skills Training” means 18 Providing training and support to help individuals live independently. It may include training on independent living skills including, but not limited to: Budgeting, self-care, housing, or transportation.
19 Process Have a process in place to identify which individuals received IL Skills Training that are associated with the Youth contract. Have a process in place to compile that information for reporting.
2. “Information and Referral” 20 The total number of inquiries about the Youth Program where this service was provided.
“Information and Referral” means 21 Providing disability specific information including, but not limited to, accessibility, housing, accommodation, and information regarding applicable laws and civil rights statues. Services and information shall be provided to individuals with disabilities, businesses, schools, state and local governments, and to all others who may request it, free of charge.
“Information and Referral” 22 – Initial Contact to the CIL with a request for information. – I&R inquires may lead to an individual opening a CSR. – If the individual already has a CSR, the information provided helped the consumer to obtain access to previously unavailable information.
23 When a request for information is received: Record the contact. Show the date (and time, if desired) of the contact. Note the information requested. Secure basic contact information and document the needs that were ID’d by the individual.
24 Process Have a process in place to identify which initial contacts for information and referrals were associated with the Youth contract. Have a process in place to compile that information for reporting.
3. IL Plan Goals Developed 25 The total number of new Goals added to IL Plans for Youth Consumers.
“IL Plan Goals Developed” means 26 The desired results identified in the Consumer’s IL Plan that meet the specific needs or requests of the Consumer in order to live independently.
27 Developing goals jointly with consumers is a critical step in ensuring that their needs are addressed and that requested services take place in a timely manner. Reporting completed goals also demonstrates to funders that the core services provided by CILs are making a difference in the lives of individuals with disabilities and in their communities
28 Process Have a process in place to identify IL Plan Goals developed for Youth. Have a process in place to compile that information for reporting.
4. IL Plan Goals Completed 29 The total number of IL Plan Goals successfully completed Youth Consumers.
30 Process Have a process in place to identify IL Plan Goals that were successfully completed for each Youth. Have a process in place to compile that information for reporting.
5. Community Options 31 Efforts during the month to increase the availability and quality of community options and capacity to meet the needs of Youth with disabilities in achieving IL goals.
32 Recreational Facilities IL Centers Accessibility of Transportation Accessibility of Businesses Accessibility for Education Community Programs Examples of Community Options: (Community Option will most likely include coordination and/or communication with other governments, businesses, or non-profit organizations.)
6. Increase Training 33 Efforts during the month to increase training for Youth with disabilities to promote self- awareness and esteem, develop self-advocacy, empowerment skills, and explore career options.
34 Career Development Aptitude Assessments and Follow-up Interviewing Skills Financial Management Transportation Skill Building Nutritional Interpersonal Communication Examples of Training: (Training may include coordination and/or communication with other governments, businesses, or non-profit organizations.)
7. Funding Sources 35 Efforts during the month to secure funding from sources other than DVR.
36 Networking with possible funders Web searches Seek alliances with organizations with like programs Co-apply for funding Contact known funders for grants or contract work Create funding activities Work to increase funding with current funders Examples of how to secure other funding: (Other Funders will most likely include coordination and/or communication with other governments, businesses, or non-profit organizations.)
8. Other Comments 37 Other efforts or statistics relevant to show work performed under the Youth contract.
38 Outreach activities. Number of individuals contacted through community information booths. Advertisements sent to underserved areas Time and Activities involved in SILC activities. SPIL committees. Board meetings Examples of “Other”:
9. Group Activities 39 The number of Group Activities held during the month.
43 CERTIFICATE OF COMPLETION for CIL Part B Report Training Is Presented To: ______________________________________ This certifies that the person named above has successfully viewed the PowerPoint course through DSHS, Division of Vocational Rehabilitation on ________.
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