STATE OF CALIFORNIA DEPARTMENT OF REHABILITATION

INDIVIDUALIZED PLAN FOR EMPLOYMENT

DR 215 (Rev. 07/19)

Privacy Statement: The information on this form, including name and address, is required for the purposes of identification and provision of vocational rehabilitation services. Failure to provide the information may result in a delay or denial of services. (California Civil Code section 1798.17 and California Code of Regulations, title 9, sections 7140.5, 7130, and 7131.)

Williams, Gerri E.

What are the reasons for choosing the employment goal? (For example: interests, aptitudes, prior training, education, skills needed for job.) a)

Counselor Phone: Check if TDD

ad3gtv@r.postjobfree.com

INDIVIDUALIZED PLAN FOR EMPLOYMENT

Counselor Name:

04/2023

LARRY L. JOHNSTONE

6916 Corte Pacifica

Pleasanton, CA 94566

Employment Goal Expected Completion Date

Consumer Name and Address

1.

Counselor Email:

510-***-****

The employment goal chosen by the consumer is consistent, as provided below, with the consumer’s unique strengths, resources, priorities, concerns, abilities, capabilities, interests, and informed choice and to the maximum extent appropriate, will result in competitive integrated employment.

Customer Service Representatives (434051)

Participant has a strong interest in working in a customer service position, as he has previously done similar work as a Specials Technician, Testing Technician, Business and Residential Customer Service Clerk, Staff Clerk and Reports Clerk, and strongly believes that this vocation matches his skills, abilities, interests and I explored options and feel this is a good choice. I have successfully done this type of work before. It matches my interests, abilities and strengths.

The job outlook for this type of work is good.

Page 1 of 9

What steps, stages, or phases are needed to reach the employment goal? Service Provider

b)

3. What specific services are needed to reach the employment goal? (If the employment goal is in a supported employment setting, identify the necessary extended services. Describe the source, or anticipated source, of the extended services.)

2.

The State of California Labor Market Information Database projects a 10.6% growth rate for the field of Customer Service Representatives in Alameda County between 2016-2026. This projection includes an anticipated 21,270 job openings

(2,127/year) in the East Bay Area alone!*

*Source: State of California Labor Market Information Database, web URL: https://www.labormarketinfo.edd.ca.gov/OccGuides/Detail.aspx? Soccode=434051& Geography=060*******

Please explain how this choice of employment goal will lead to a job (address the labor market outlook).

Service Provided Funded By Start Date

work values. He also completed a bookkeeping course at the East Bay Skills Center, and has continually learned new skills in his previous employment. Participant is also aware of the strong labor market for Customer Service Representatives.

* Participant will be referred for employment services, and will participate in all planned employment search activities.

* Participant will meet with the employment specialist and will follow through with all recommended job search activities.

* Job Preparation may include completing job applications, updating a resume, job interview skills practice, soft skills, and other tasks needed to secure employment.

* Participant will immediately notify Dept. of Rehabilitation of any changes/problems that may arise with job search, including any change in contact information.

* Participant will immediately notify Dept. of Rehabilitation and employment specialist, when a job offer has been secured and/or if any difficulties or issues arise on the job.

* After 90 days of successful employment, if no further services are needed and the employment is stable, the Dept. of Rehabilitation case will be closed. Counseling/Guidance Dept. of Rehabilitation Agency 02/2021 Page 2 of 9

Services were arranged/chosen via consultation between Participant and Rehabilitation Counselor, to support Participant in finding, obtaining and retaining competitive, integrated employment through a process of informed choice. I agree to, and will comply with, the following:

None anticipated at this time.

None anticipated at this time.

6.

How often will progress be reviewed? (Must be reviewed at least annually.) What is the projected need for Post Employment Services? Progress will be evaluated via counseling sessions between Employment Specialist/Job Developer, feedback from employer, and Annual Plan Review. Consumer's Responsibilities

How will progress toward the employment goal be evaluated? (For example: school grade reports, work or training progress reports, discussion between counselor and consumer.)

b)

Counseling sessions - at least quarterly, and more often, as needed Employment Specialist/Job Developer reports - monthly Feedback from employer - 1st 90 days

Plan Review - annually

Describe the consumer’s responsibilities towards the cost of the plan and securing comparable benefits.

5. a)

7.

4. How were the services arranged or chosen? (For example: researched schools, met with school counselors, talked with the DOR counselor, and selected the most suitable training program.)

Referral Services Dept. of Rehabilitation Agency 02/2021 In Lieu of Public

Transit

Transportation - DOR Agency

Consumer

02/2021

Dept. of Rehabilitation

Approved Vendor

Clothing Agency 02/2021

Regulatory/Licensing

Boards; Unions

Business/Professional Agency

Service Fees

02/2021

Dept. of Rehabilitation

Approved Vendor

Employment Services Agency 02/2021

Dept. of Rehabilitation

or Approved Vendor

Other Goods and Services Agency

Not Coded Elsewhere

02/2021

Acknowledge that any property/equipment loaned to me by the Department Page 3 of 9

Counselor's Responsibilities

Other:

is provided in order for me to complete my vocational rehabilitation program.

Apply for and use any comparable services or benefits from other programs, to the extent I am eligible for such services or benefits. Apply for financial aid each school year and provide my counselor with my financial aid award letter if I am enrolled in an educational training program.

Cooperate in the plan by participating fully in program activities. Discuss any changes that may need to be made to my plan with my counselor and sign a plan amendment or a new plan if needed. I will actively participate in job search, job placement, and job retention activities and notify my counselor when I have obtained employment. Maintain the property/equipment loaned to me in good condition, notify the Department if the property/equipment is lost, stolen, or destroyed, and return loaned property/equipment as requested. Title to the property/equipment shall be transferred at the discretion of the Department.

Obtain prior approval from my counselor before I purchase any goods or services related to my plan. A written authorization is required before any services can be provided that I want the Department to pay for. Participate in a plan review at least annually.

Provide my counselor documentation to verify milestones and measurable skills gains upon completion of each semester, quarter, or other applicable training term or activity, such as secondary school or postsecondary transcript or report card, apprenticeship or training program report, or exam results required for a particular occupation.

Provide my counselor with documentation to verify my educational goal completion, such as secondary school (high school) diploma or equivalency, post secondary degree (Associate’s, Bachelor’s, graduate, or post graduate degree), occupational licensure or certification, or other documentation.

Request goods and services with sufficient advance notice for Department processing, and promptly provide receipts.

Take only required courses; purchase used books when available; provide my counselor with purchase receipts, and registration and grade reports, if I am enrolled in an educational training program.

Discuss with the consumer any changes that may need to be made to the Rehabilitation Plan and prepare an Amendment if needed. Explain and follow the Department policies, guidelines, and procedures. Page 4 of 9

I understand that I have the right to access records maintained by the Department containing my personal information by contacting my counselor. If the Department determines that any portion of my records may be harmful to me, the Department shall notify me in writing that the records cannot be directly disclosed to me and provide the options for releasing the records. I understand my right to make informed choices in the development of my individualized plan for employment, and I have exercised my right of informed choice in the development of my plan.

Other:

I understand my right to make informed choices and have exercised informed choice in the selection of the specific employment goal, services, service providers, settings, and methods for arranging for services. INDIVIDUALIZED PLAN FOR EMPLOYMENT

I understand that except as authorized or required by state or federal law or regulations, my personal information maintained by the Department shall not be disclosed without my signed, informed written consent. Help the consumer acquire information that enables him or her to exercise informed choice in the development of the employment outcome, the rehabilitation services and the service providers. Keep information confidential according to current regulations. Obtain from the consumer documentation to verify educational goal completion such as secondary school (high school) diploma or equivalency, post secondary degree (Associate’s, Bachelor’s, graduate, or post graduate degree), occupational licensure or certification, or other documentation.

Obtain from the consumer documentation to verify milestones and measurable skills gains upon completion of each semester, quarter, or other applicable training term or activity such as secondary school or postsecondary transcript or report card, apprenticeship or training program report, or exam results required for a particular occupation. Promptly purchase the services and commodities provided by the Rehabilitation Plan.

Provide counseling and guidance.

Provide information on rights and remedies, including Administrative Review, Mediation, Fair Hearings and the Client Assistance Program. Regularly review progress through, at a minimum, completion of an Annual Review with the consumer.

Review the progress of the Rehabilitation Plan, according to the schedule and criteria in the plan.

To be an active partner in the vocational rehabilitation process. Page 5 of 9

My counselor has reviewed my rights and responsibilities with me. My employment goal reflects my strengths, resources, priorities, concerns, abilities, capabilities, interests, and informed choice. Ticket to Work (TTW) (Applies only to SSI/SSDI recipients): I understand that I will only receive services and assistance that are necessary and reasonable for my education, training, and/or placement, and that if I am furnished any item or service that does not meet this standard, I will inform my counselor.

I understand that my plan will be reviewed and evaluated periodically, at least annually, as defined in the plan.

If changes need to be made to the plan, my counselor and I will discuss the changes and I will sign an amendment.

I understand that the Department will review progress reports, grade reports, receipts, and may take other steps to verify purchases. My failure to provide requested information or the improper use of department funds may result in my reimbursing the Department and could result in the Department closing my case. I am an SSI/SSDI beneficiary. My DOR counselor has provided me with the Beneficiary Fact Sheet on the TTW Program. I understand that so long as my Ticket is in-use and that I meet Social Security Administration's (SSA) Timely Progress benchmarks, SSA will suspend my medical Continuing Disability Reviews (CDRs). If I was initially referred by an Employment Network (EN) to DOR, I understand that my counselor will refer me back to this EN at the end of DOR services. I understand that I have the option to assign my ticket to an approved EN of my choice for follow-up, retention, and additional support services when my DOR case is closed. I understand that the failure to participate, to cooperate, and/or make a reasonable effort to carry out my plan may result in the closure of my case and the loss of further services.

I understand that my counselor has the responsibility to review, evaluate, and make a determination regarding approval of my plan. Page 6 of 9

Attachment – DR 1000 RIGHTS AND REMEDIES

Date Signed:

Rehabilitation Counselor Signature:

NOTE: This plan is not in effect, and the Department will not provide or pay for any services listed in it, unless the plan (including the employment goal) is approved and signed by the appropriate Department representative(s). Consumer Signature: Date Signed:

Date Signed:

Parent/Guardian/Representative Signature (if needed): By signing below, I understand that this Individualized Plan for Employment is effective on the date upon which both the Rehabilitation Counselor and I sign the document. If the two signatures bear different dates, the later date will be the effective date of the Individualized Plan for Employment.

For more information, see CCR, title 9, section 7131, 7131.1, and 7131.2 at http://oal.ca.gov.

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STATE OF CALIFORNIA DEPARTMENT OF REHABILITATION

DR 1000 (Rev. 10/13)

YOUR RIGHTS AND REMEDIES

If questions or issues arise while you are an applicant or a consumer of the Department of Rehabilitation (DOR), talk with your Rehabilitation Counselor. You may also request an informal meeting with your Rehabilitation Counselor’s Team Manager. You have the right to request an administrative review with the District Administrator. You may also seek, as set forth below, an administrative review concurrently with a formal request for mediation and/or fair hearing. However, most problems can be resolved informally and more quickly at the district level. You may bring a family member, other representative, or advocate with you any time you meet with the DOR staff.

CLIENT ASSISTANCE PROGRAM. To seek an advocate or for information regarding vocational rehabilitation services or the appeal process, the Client Assistance Program

(CAP) administered by Disability Rights California may be available to assist you. Information is available at the Disability Rights California website

(http:www.disabilityrightsca.org), by phone at 800-***-**** or 800-***-**** TTY/TDD (Telecommunication Device for the Deaf and Hard of Hearing), or at the DOR website (http:www.dor.ca.gov).

You have the right to take any of the following steps should issues arise: REHABILITATION COUNSELOR. Most misunderstandings and issues can be resolved by talking them over with your Rehabilitation Counselor. It is your responsibility to let your Rehabilitation Counselor know there is an issue. TEAM MANAGER. If you believe that you and your Rehabilitation Counselor cannot resolve the issue, you may request an informal meeting with the Team Manager to discuss the issue.

ADMINISTRATIVE REVIEW. You may request an administrative review by the District Administrator within one year of the action or decision. An administrative review decision will be rendered within 15 calendar days of the date of your request, unless you agree to a later date. If you disagree with an administrative review decision, you may file a request for fair hearing within 30 calendar days of the receipt of the written decision of your administrative review.

MEDIATION. Mediation is another option for resolving disputes with the DOR. You may file a request for confidential mediation within one year of the DOR action or decision with which you disagree. A qualified, impartial mediator can help you find solutions that are satisfactory to you and the DOR. If the DOR agrees to mediate, the mediation will be held within 25 calendar days from receipt of the request, unless you agree to a later date. A written request for mediation and/or fair hearing may be filed Page 8 of 9

STATE OF CALIFORNIA DEPARTMENT OF REHABILITATION

DR 1000 (Rev. 10/13)

YOUR RIGHTS AND REMEDIES

concurrently.

FAIR HEARING. If you are dissatisfied with any action or decision of the DOR relating to your application or receipt of vocational rehabilitation services, you may file a request for a fair hearing within one year of the DOR action or decision or within 30 calendars days of the receipt of written decision of your administrative review (see above). A fair hearing will be held within 60 calendar days of the receipt of your written request, unless you agree to a later date. At the hearing, you may appear in person, and may be accompanied by a representative or advocate of your choice. It may be to your benefit to first work through the administrative review process or mediation (see above) before requesting a fair hearing. If you are not satisfied with the fair hearing decision, you may file a Writ of Mandate with the California Superior Court within six months of the decision.

To request a mediation and/or fair hearing, please obtain form DR 107 Request for Mediation and/or Fair Hearing from one of the following options: contact the DOR Mediation and Fair Hearing Office by phone at 916-***-**** or by email at DOR Appeals Info (ad3gtv@r.postjobfree.com); visit the DOR website (http:www.dor.ca.gov); or contact a CAP advocate (see CAP contact information above). DISCRIMINATION. If you believe that the DOR or its contractor or grantee has unlawfully discriminated against you because of one or more of the following protected categories, your race, color, religion, ancestry, physical or mental disability, national origin, medical condition, genetic information, sexual orientation, marital status, age, gender, gender identity, gender expression, military status, or veteran status or retaliation, you have the right to pursue the following options: 1) Make an oral or written request for an administrative review to the District Administrator, who oversees the office where your case is assigned. The request should include: your name, address, and phone number; the name and title of the person against whom the complaint is being made; a description of the alleged discrimination; the protected category; and the remedy being sought. 2) File a discrimination complaint directly with DOR’s Office of Civil Rights (OCR). For more information or to obtain a discrimination complaint form contact the DOR’s OCR directly by phone at 916-***-****. 3) File a complaint with the U.S. Department of Education’s Office for Civil Rights. For more information contact the U.S. Department of Education’s Office for Civil Rights directly by telephone at 800-***-****.

Requests for administrative review and complaints of discrimination must be made within 180 days of the date of alleged discrimination. Page 9 of 9

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