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wr;,,t* <br />Division of Vocational Rehabilitation (DVR) <br />Exhibit E: <br />School-to-Work Billing Checklist <br />lnstructions: <br />1. The Student Guide is sent monthly to the Student's Team, including the DVR Counselor. <br />Z. 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 />SVRSctr oolT'oWonk(CIdsh s.uta.gov. <br />Exhibit E: School-to-Work Billing Checklist <br />DSHS 11-195A (04t2026) <br />Month and YearContractor <br />Date of SignatureSignature <br />Student lnitialsAFP Number <br />To be filled out bY DVR gtaff OnlY: <br />and date below to confirm <br />items received and to authorize <br />DVR staff signAmount <br />BilledActivity Billed <br />2 0 00$I tntat<e Meeting <br />3 0 00$E Assessment <br />1 0 00$I .loO Seeker Tools <br />2 0 00$[ .tob offer <br />1 0 00$I Employment Verification <br />$ 5,000I Stabilization <br />$Total Billing