Provider Forms

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Number Form Title Word PDF Instructions Revised
DARS1050 Ticket to Work Partnership Plus, Employment Advancement Payment DARS1050, Ticket to Work Partnership Plus, Employment Advancement PaymentWord DARS1050, Ticket to Work Partnership Plus, Employment Advancement PaymentPDF DARS1050INST, Ticket to Work Partnership Plus, Employment Advancement PaymentInstructions 01/01/2010
DARS1487 Designation of Applicant or Consumer Representative DARS1487, Designation of Applicant or Consumer RepresentativeWord DARS1487, Designation of Applicant or Consumer RepresentativePDF N/A 10/01/2006
DARS1612 Career and Community Support Analysis DARS1612, Career and Community Support AnalysisWord N/A N/A 03/01/2012
DARS1613 Supported Employment Services Plan-Part 1 DARS1613, Supported Employment Services Plan-Part 1Word DARS1613, Supported Employment Services Plan-Part 1PDF N/A 02/01/2011
DARS1614 Supported Employment Services Plan-Part 2 DARS1614, Supported Employment Services Plan-Part 2Word N/A N/A 03/01/2012
DARS1615 Supported Employment Support Summary DARS1615, Supported Employment Support SummaryWord N/A N/A 03/01/2012
DARS1616 Job Stability or Service Closure Justification Summary DARS1616, Job Stability or Service Closure Justification SummaryWord N/A N/A 03/01/2012
DARS1800 Supported Self-Employment Services Plan (SSESP) DARS1800, Supported Self-Employment Services Plan (SSESP)Word DARS1800, Supported Self-Employment Services Plan (SSESP)PDF DARS1800INST, Supported Self-Employment Services Plan (SSESP)Instructions 04/01/2011
DARS1801 Concept Development and Feasibility Study Worksheet DARS1801, Concept Development and Feasibility Study WorksheetWord DARS1801, Concept Development and Feasibility Study WorksheetPDF DARS1801INST, Concept Development and Feasibility Study WorksheetInstructions 04/01/2011
DARS1802 Planning Meeting Record DARS1802, Planning Meeting RecordWord DARS1802, Planning Meeting RecordPDF DARS1802INST, Planning Meeting RecordInstructions 12/01/2010
DARS1803-1 Business Plan Support Summary Report DARS1803-1, Business Plan Support Summary ReportWord DARS1803-1, Business Plan Support Summary ReportPDF DARS1803-1INST, Business Plan Support Summary ReportInstructions 12/01/2010
DARS1803-2 Business Plan DARS1803-2, Business PlanWord N/A DARS1803-2INST, Business PlanInstructions 12/01/2010
DARS1804 Supported Self-Employment Financial Projection Spreadsheet DARS1804, Supported Self-Employment Financial Projection SpreadsheetExcel N/A N/A 05/01/2013
DARS1805 Supported Self-Employment Financial Actual Spreadsheet DARS1805, Supported Self-Employment Financial Actual SpreadsheetExcel N/A N/A 05/01/2013
DARS1806 Supported Self-Employment Support Summary (SSE-SS) DARS1806, Supported Self-Employment Support Summary (SSE-SS)Word DARS1806, Supported Self-Employment Support Summary (SSE-SS)PDF DARS1806INST, Supported Self-Employment Support Summary (SSE-SS)Instructions12/01/2010
DARS3100 General Physical Examination Report DARS3100, General Physical Examination ReportWord DARS3100, General Physical Examination ReportPDF N/A 11/01/2006
DARS3101 Consultant Review DARS3101, Consultant ReviewWord DARS3101, Consultant ReviewPDF N/A 01/01/2007
DARS3102 Pulmonary Evaluation Report DARS3102, Pulmonary Evaluation ReportWord DARS3102, Pulmonary Evaluation ReportPDF N/A 01/01/2007
DARS3103 Cardiac Evaluation Report DARS3103, Cardiac Evaluation ReportWord DARS3103, Cardiac Evaluation ReportPDF DARS3103INST, Cardiac Evaluation ReportInstructions 01/01/2007
DARS3104 Visual Evaluation Report DARS3104, Visual Evaluation ReportWord DARS3104, Visual Evaluation ReportPDF DARS3104INST, Visual Evaluation ReportInstructions 11/01/2006
DARS3105 Hearing Evaluation Report DARS3105, Hearing Evaluation ReportWord DARS3105, Hearing Evaluation ReportPDF N/A 05/01/2009
DARS3106 Work Restriction Checklist DARS3106, Work Restriction ChecklistWord N/A DARS3106INST, Work Restriction ChecklistInstructions 10/03/2011
DARS3108 Dental Report DARS3108, Dental ReportWord DARS3108, Dental ReportPDF DARS3108INST, Dental ReportInstructions 11/01/2006
DARS3110 Surgery and Treatment Recommendations DARS3110, Surgery and Treatment RecommendationsWord DARS3110, Surgery and Treatment RecommendationsPDF DARS3110INST, Surgery and Treatment RecommendationsInstructions 09/01/2009
DARS3111 End-Stage Renal Disease Evaluation DARS3111, End-Stage Renal Disease EvaluationWord DARS3111, End-Stage Renal Disease EvaluationPDF DARS3111INST, End-Stage Renal Disease EvaluationInstructions 11/01/2006
DARS3112 Cancer Disability Medical Report DARS3112, Cancer Disability Medical ReportWord DARS3112, Cancer Disability Medical ReportPDF DARS3112INST, Cancer Disability Medical ReportInstructions 02/01/2007
DARS3140 Community Rehabilitation Program Information Sheet DARS3140, Community Rehabilitation Program Information SheetWord N/A N/A 09/01/2011
DARS3150 Application - Community Rehabilitation Program (CRP) Providers DARS3150, Application - Community Rehabilitation Program (CRP) ProvidersWord DARS3150, Application - Community Rehabilitation Program (CRP) ProvidersPDF N/A 02/01/2011
DARS3151 Personnel Activity Report DARS3151, Personnel Activity ReportWord DARS3151, Personnel Activity ReportPDF N/A 02/01/2006
DARS3152 Equipment Inventory List DARS3152, Equipment Inventory ListWord DARS3152, Equipment Inventory ListPDF DARS3152INST, Equipment Inventory ListInstructions 02/01/2006
DARS3153 Request for Advance or Reimbursement (RAR) DARS3153, Request for Advance or ReimbursementWord DARS3153, Request for Advance or ReimbursementPDF DARS3153INST, Request for Advance or ReimbursementInstructions 09/01/2011
DARS3155 Budget Revision Request DARS3155, Budget Revision RequestWord DARS3155, Budget Revision RequestPDF DARS3155INST, Budget Revision RequestInstructions 09/01/2011
DARS3156 Quarterly Program Income Report DARS3156, Quarterly Program Income ReportWord DARS3156, Quarterly Program Income ReportPDF DARS3156INST, Quarterly Program Income ReportInstructions 09/01/2011
DARS3157 Quarterly Financial Report and Analysis N/A DARS3157, Quarterly Financial Report and AnalysisPDF DARS3157INST, Instructions for Quarterly Financial Report and AnalysisInstructions 09/01/2011
DARS3159 Final Report of Expenditures DARS3159, Final Report of ExpendituresWord DARS3159, Final Report of ExpendituresPDF DARS3159INST, Instructions for Final Report of ExpendituresInstructions 09/01/2011
DARS3160 Quarterly Program Performance Report DARS3160, Quarterly Program Performance ReportWord DARS3160, Quarterly Program Performance ReportPDF DARS3160INST, Instructions for Quarterly Program Performance ReportInstructions 09/01/2011
DARS3161 Consumer Demographic Information N/A DARS3161, Consumer Demographic InformationPDF DARS3161INST, Instructions for Consumer Demographic InformationInstructions 09/01/2011
DARS3310 Embedded Training Proposal DARS3310, Embedded Training ProposalWord N/A N/A 08/01/2012
DARS3311 Embedded Training Plan and Report DARS3311, Embedded Training Plan and ReportWord N/A N/A 08/01/2012
DARS3312 Progress Log DARS3312, Progress LogWord N/A N/A 08/01/2012
DARS3313 Embedded Training Placement Report DARS3313, Embedded Training Placement ReportWord N/A N/A 08/01/2012
DARS3406 Counseling Progress Report DARS3406, Counseling Progress ReportWord DARS3406, Counseling Progress ReportPDF DARS3406INST, Instructions for Counseling Progress ReportInstructions 12/01/2010
DARS3407 Training Progress Report DARS3407, Training Progress ReportWord DARS3407, Training Progress ReportPDF N/A 01/01/2007
DARS3408 Vehicle Modification Evaluation DARS3408, Vehicle Modification EvaluationWord DARS3408, Vehicle Modification EvaluationPDF N/A 09/01/2006
DARS3415 Workers' Compensation Contact Verification Letter DARS3415, Workers' Compensation Contact Verification LetterWord N/A DARS3415INST, Instructions for Workers' Compensation Contact Verification LetterInstructions 05/01/2013
DARS3422 Reduced Payment Agreement DARS3422, Reduced Payment AgreementWord DARS3422, Reduced Payment AgreementPDF N/A 02/01/2007
DARS3430 Job Placement Services–Referral DARS3430, Job Placement Services-ReferralWord DARS3430, Job Placement Services-ReferralPDF N/A 12/01/2008
DARS3431 Job Placement Services–Plan DARS3431, Job Placement Services-PlanWord DARS3431, Job Placement Services-PlanPDF N/A 12/01/2008
DARS3432A Job Placement Services–Support Summary Benchmark A, After First Day of Paid Employment DARS3432A, Job Placement Services-Support Summary Benchmark A, After First Day of Paid EmploymentWord N/A N/A 12/01/2011
DARS3432B Job Placement Services–Support Summary Benchmark B, After 45 Days of Paid Employment DARS3432B, Job Placement Services-Support Summary Benchmark B, After 45 Days of Paid EmploymentWord N/A N/A 12/01/2011
DARS3432C Job Placement Services–Support Summary Benchmark C, After 90 Days of Paid Employment DARS3432C, Job Placement Services-Support Summary Benchmark C, After 90 Days of Paid EmploymentWord N/A N/A 12/01/2011
DARS3453 Work/Residential Community Rehabilitation Programs, Monthly Progress Report DARS3453, Work-Oriented Residential Community Rehabilitation Programs, Monthly Progress ReportWord DARS3453, Work-Oriented Residential Community Rehabilitation Programs, Monthly Progress ReportPDF N/A 02/01/2006
DARS3454 Excellence in Service Provision CRS Case Review DARS3454, Excellence in Service Provision CRS Case ReviewWord N/A N/A 09/01/2011
DARS3455 Community Rehabilitation Program Staff Information DARS3455, Community Rehabilitation Program Staff InformationWord N/A N/A 10/03/2011
DARS3456 Compliance and Quality Case Review DARS3456, Compliance and Quality Case ReviewWord N/A DARS3456, Instructions for Compliance and Quality Case ReviewInstructions 09/01/2011
DARS3458 Job Coach Services Time Log DARS3458, Job Coach Services Time LogWord N/A N/A 12/01/2011
DARS3472 Contracted Service Modification DARS3472, Contracted Service ModificationWord DARS3472, Contracted Service ModificationPDF N/A 02/01/2007
DARS3480 Referral for Vocational Evaluation DARS3480, Referral for Vocational EvaluationWord N/A N/A 06/01/2012
DARS3482 Personal Social-Adjustment Class Attendance DARS3482, Personal Social-Adjustment Class AttendanceWord DARS3482, Personal Social-Adjustment Class AttendancePDF N/A 02/01/2007
DARS3484 Community Rehabilitation Program, Individualized Adjustment Plan DARS3484, Community Rehabilitation Program, Individualized Adjustment PlanWord DARS3484, Community Rehabilitation Program, Individualized Adjustment PlanPDF N/A 11/01/2007
DARS3485 Community Rehabilitation Program, Individualized Job Placement Plan DARS3485, Community Rehabilitation Program, Individualized Job Placement PlanWord DARS3485, Community Rehabilitation Program, Individualized Job Placement PlanPDF N/A 11/01/2007
DARS3488 Community Rehabilitation Program, Vocational Evaluation Report Checklist DARS3488, Community Rehabilitation Program, Vocational Evaluation Report ChecklistWord DARS3488, Community Rehabilitation Program, Vocational Evaluation Report ChecklistPDF N/A 11/01/2007
DARS3490 DARS3490, Temporary Waiver of CRP Credentials DARS3490, Temporary Waiver of CRP CredentialsWord N/A N/A 01/09/2012
DARS3494 Mechanic's Evaluation - Used Vehicle DARS3494, Mechanic's Evaluation - Used VehicleWord DARS3494, Mechanic's Evaluation - Used VehiclePDF N/A 09/01/2006
DARS5163 Individualized Plan for Employment (IPE)—Vocational Rehabilitation Services DARS5163, Individualized Plan for Employment (IPE)—Vocational Rehabilitation ServicesWord N/A N/A 02/01/2011
DARS5163-S Plan Individualizado de Empleo (IPE)—Servicios de Rehabilitación Vocacional DARS5163-S, Plan Individualizado de Empleo (IPE)—Servicios de Rehabilitación VocacionalWord N/A N/A 02/01/2011
DARS5164 Individualized Written Rehabilitation Plan—Comprehensive Rehabilitation Services DARS5164, Individualized Written Rehabilitation Plan—Comprehensive Rehabilitation ServicesWord N/A N/A 02/01/2011