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00o DSHS Division of Vocational Rehabilitation Sections to be filled <br />out by Contractor <br />Exhibit F: <br />Sections to be filled <br />School -to -Work Billing Checklist <br />out by DVR <br />Contractor Month and Year <br />Signature Date of Signature <br />AFP Number <br />Student Initials <br />Amount <br />DVR Staff Verification (Sign and Date) to confirm <br />Activity Billed <br />Billed <br />$ 3,000 <br />items received and payment authorization <br />❑ Intake Meeting <br />❑ Assessment <br />$ 2,000 <br />❑ Job Seeker Tools <br />$ 1,000 <br />❑ Job Offer <br />$ 2,000 <br />❑ Employment Verification <br />$ 1,000 <br />❑ Stabilization <br />$ 5,000 <br />Total Billing: <br />$ <br />Instructions: <br />1. The Student Guide is sent monthly to the Student's Team, including the DVR Counselor. <br />2. The Contractor checks the appropriate box(es) as the corresponding activities are completed in <br />the Student Guide (one form per student). <br />3. The Contractor submits this completed form to the assigned DVR Counselor. <br />4. The DVR Counselor confirms information from monthly submissions of the Student Guide, <br />verifies activities were completed, then signs and dates the checklist. <br />5. The DVR Counselor submits for payment. <br />Notables: <br />• The Student Guide serves as documentation for proof of completion for the payment/activity <br />point. <br />• The Contractor submits no less than three (3) separate checklists to the assigned DVR <br />Counselor for each student (Submitting all payment points separately is also an option). <br />Any questions, please contact the School -to -Work Team at <br />D V RS c h o oiTo W ❑ rk(cD ds hs.wa. qov . <br />Exhibit F: School -to -Work Billing Checklist <br />DSHS 11-195 (05/2025) <br />