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Utah Division of Real Estate (DRE) aims to protect the public and promote responsible business practices through education, licensure, and regulation of real estate, mortgage, and appraisal professionals

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DWS-USOR 94
Rev. 09/2019
State of Utah
Department of Workforce Services
WORK STRATEGY ASSESSMENT
This form is to be completed by the VR Counselor, Community Rehabilitation Program (CRP)
Provider, and the client. The assessment is due when the team meets to review the results, agree to
goals, and sign the assessment.
Counselor Referral Page
Client Name:
Address:
City:
State:
ZIP:
CRP Referring to:
Client Phone:
Client Cell:
Guardianship:
Yes No
If yes, Parent/Guardian name and phone:
Referral question:
Resources available to Client (check all that apply)
Extended Services Provider (Supported Employment)
Division of Services for People with Disabilities (DSPD)
Mental Health Provider:
Partnership Plus (TTW)
Other:
Health Insurance (check all that apply)
Medicaid
Medicare
Parent’s Insurance
Spouse’s Insurance
Other:
Social Security Benefits
Supplemental Security Income (SSI)
Social Security Disability Insurance (SSDI)
Benefits Planning
Completed
Pending, Date Scheduled:
Not Applicable
Benefits Summary Info:
Other Services/Benefits:
Describe the following as it applies to client:
Current Work Skills (knowledge, skills, and abilities):
Work Skill Development Needs:
Jobs of Interest:
Interpersonal/Social Skills: (explain issues regarding personal space, ability to communicate,
informal/formal speech):
Identified Assistive Technology Needs (glasses, UCAT device, etc):
Communication Needs (interpreter, etc):
Behavioral/Self-regulation:
Activities of Daily Living (hygiene, meal prep, etc.):
Additional Information:
Family Issues/Supports:
Criminal Background (expungement, etc.):
School/Academic (can include behavioral information):
COMMUNITY REHABILITATION PROGRAM
Observation and Report
Work Assessment
Should include a worksite assessment with observations and assessment of simulated or
true work activities. Work activities must simulate those found in a CIE work industry of
interest as indicated above. (4 hours)
Areas to Assess and Report
Soft skills
Job experiences (work sample)
Transferable skills
Interpersonal skills
Client interest (job goal)
Self-direction
Physical abilities
How the client reacts to criticism
Worksite Simulation Location:
Observations:
Natural Support Assessment (1 hour)
Areas to Monitor and Report
Family support
Other natural supports
Parent/Guardian expectations
How the client reacts to working with others
Safety concerns
Professional boundaries
Observations:
Life Skills (1 hour)
Areas to Address and Report
Presentation: Personal appearance and hygiene
Self-care including meal prep/grocery shopping
Financial literacy
Observations:
Transportation Assessment (30 min)
Areas to Assess and Report
Business or industries available close to the client
Proximity of employment opportunities to home
Transportation options available:
Public:
Private transportation:
Observations:
Computer Skill Assessment (30 min)
Areas to Assess and Report
Ability to complete online application
Social Media (social skills and protocol)
Other skills (typing test, 10 key, etc.):
Observations:
Interview Skill Assessment (1 hour)
Areas to Monitor and Report
Mock Interview
Communication skills
Body language/posture
Interview-appropriate dress
Listening skills
Ability to answer directed questions
Observations:
Other Observations:
Recommendations
CRP Recommended strategy for achieving Competitive Integrated Employment
Planned Job Search hours/week:
Life Skills needed:
Life Skills hours requested:
Recommended target occupations:
Recommended supports on the job:
TEAM SECTION
CRP, VR Counselor, DSPD, and Client
Community Rehabilitation Program Name:
Assigned Employment Specialist/Job Coach:
ACRE Certified?
Yes No
Joint VR/CRP Recommendations for Job Development Supports:
Joint VR/CRP Recommendations for Ongoing Supports:
Job Goal (must align with IPE goal):
Industry Targeted Pay Range:
Benefits/Other:
Hours available to work (check all that apply):
Full Time
Part Time
< 10 hours/wk
Other:
Days
Graveyard
Swing shift
Weekends
Other:
By signing this form the team acknowledges that the job goal and parameters outlined above will be
the focus of their services for this client and that any desired change to job goal, or placement
requires documented agreement by team prior to implementation.
Client Signature:
Date:
CRP Signature:
Date:
VR Counselor Signature:
Date:
Equal Opportunity Employer/Program
Auxiliary aids and services are available upon request to individuals with disabilities by calling 801-526-9240. Individuals
who are deaf, hard of hearing, or have speech impairments may call Relay Utah by dialing 711. Spanish Relay Utah: 1-888-346-3162.
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Completed 25 June 2021

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