Assistive Technology / Rehabilitation Technology

Assistive Technology / Rehabilitation Technology Evaluation

Authorization #	Enter AV #.
Aware Participant ID	Enter Aware Participant ID

VR District Office: Click arrow to select office.	Vendor: Click to enter Vendor Name
VRC Name: Click to enter.	SFS Vendor ID: SFS Vendor ID.
Report Date: Click to enter a date.

Customer First Name: Click to enter	Customer Last Name: Click to enter
Customer Phone Number: Click to enter
Customer Email Address: Click to enter

Assistive Technology Evaluation Details
Number of Hours Authorized: Enter number of units authorized Number of Hours Used: Click here to enter number of units used Note: Unit = 1 Hour (20 Max)
Employment Outcome: Enter Employment Outcome (as noted in referral).
Please indicate the Impediments to Achieving the Employment Outcome: Enter impediments to employment outcome here.
Please describe how the assistive technology device(s) and/or service(s),recommended in the report, will address the customer’s functional limitations in terms of participation in training and/or other services needed to assist in meeting their employment outcome. Enter description of how assistive technology will assist individual in achieving an employment outcome.
Additional Information and Recommendations: Enter Recommendations here.
Was this report completed within 10 business days of the last service?
☐ Yes	☐ No
If not, please explain: Click here to enter text.
Was the VRC offered a chance to attend a conference at the conclusion of the service? (Maintain documentation of this in the customer record)
☐ Yes	☐ No

Completed By:
Enter staff name here.	Enter staff title here.
Printed Name	Title
Phone: Enter phone number.	Email: Enter email.