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July 10, 2014 Page 1

Your Name: Date of Birth: Phone #/Email Address: Today’s Date:

- -

Name of Services Coordinator (SC) or Personal Agent (PA):

SC/PA Phone # and Email Address: Name of Brokerage or CDDP:

1A. Select the Funding Source for Your Current ODDS services (Check All That Apply): Comprehensive Waiver K-Plan Support Services Waiver I receive state-funded services only (see directions if this is selected) Other( specify): 1B. If you do not currently receive services through an ODDS waiver, are you eligible to receive services through the

Comprehensive or Support Services Waiver? Yes No (see directions if “no” is selected)

2A. Your Current Employment Status: Check the ODDS-funded employment service (s) that you have participated in during the

last 90 days: Individual Employment Small Group Employment Employment Path Community Employment Path

Facility Discovery/Career Exploration None of the Above

2B. I am employed but do not use the applicable ODDS employment service. The applicable ODDS employment service would

be: Individual Employment Small Group Employment

2C. For each service selected in 2A, provide the following information:

Service Provider Name& City Contact Person’s Name, Phone #

& Email Address

Are You Still Receiving this Service? Discovery/Career

Exploration

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July 10, 2014 Page 2

Job Coaching Yes No

Small Group Employment Yes No Employment Path Community Yes No Employment Path Facility Yes No

2D. Your Current K-Plan Services: Check the box or boxes of the following K-Plan services that you have participated in during the last 90 days: Day Support Activities Community Day Support Activities Facility Neither

2E. For each service selected in 2D, provide the following information:

Service Provider Name & City Contact Person’s Name, Phone #

& Email Address

Are You Still Receiving this Service? Day Support Activities

Community

Yes No

Day Support Activities Facility

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July 10, 2014 Page 3

3. Your employment goals for your upcoming ISP year:

3A. Students (age 18-20) If you are under the age of 22 and are still attending school include yourself under this category only.

Attending school and do not want to work now. Expected date of exit from school: Date by which a Career Development Plan and Vocational Assessment (CDP) will be completed:

Attending school and I do want to work now. Complete a CDP.

3B. Working age adults (age 21-60) must choose one of the following statements: Please read instructions for guidance on making the proper selection. If you are at least 18 years old and have exited school include yourself under this category only.

Employed in an integrated employment setting and I want to: (Check all that apply. Except for Retire, complete a CDP) Retain current job

Advance in current job (more hours, raise, new skills, promotion, etc.) Get a new job

Get an additional job

Retire – I am 60 or will be 60 this ISP year.

Currently unemployed and wants integrated employment. Complete a CDP.

Currently unemployed and interested in integrated employment. Complete a CDP.

Not interested in integrated employment now but may be interested in the future. Complete a CDP. Currently unemployed and wants to retire. I am 60 or will be 60 this ISP year. Do not complete a CDP.

Not interested in integrated employment now and not interested in integrated employment in the future. Do not complete

a CDP. Instead, complete My Decision Not to Explore, Pursue, Obtain or Maintain Community Employment For My Upcoming

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July 10, 2014 Page 4 4: People who helped me to create “My Declaration”:

Printed Name Signature Role in My Life Employer (Only needed

if the person is paid to provide ODDS or VR services to you)

Phone # & Email Address

X

P e rso n

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July 10, 2014 Page 5 Instructions

From July 1, 2014 – December 31, 2014, the “My Annual Declaration of My Employment Goals for My ISP Year” (My

Declaration) and the accompanying “My Career Development Plan and Vocational Assessment” (CDP) and/or, “My Decision Not to Explore, Pursue, Obtain or Maintain Community Employment for My Upcoming ISP Year and in the Future and

Vocational Assessment,” (MDE) shall be applied to:

 People who are currently in a sheltered workshops; and

 Transition Age Youth (18-21) within 1 year of exiting High School or a High School Transition Program; and  Anyone who is at least 18 and wants a CDP and is seeking integrated employment

Based on the choices made in “My Declaration”, the individual with the assistance of their Services Coordinator (SC) or Personal Agent (PA), and others the individual wishes to be involved in this process, shall either complete a:

CDP: This will help the individual and their ISP team to identify employment goals and how they will be achieved; or

MDE: This will provide information about how the individual made the decision not to work and help to identify if there are other strategies to help the individual to explore, pursue, obtain or maintain employment.

If an individual is 60 or will be 60 in their ISP year and they do not wish to explore, pursue, obtain or maintain community employment, they will not have to complete a CDP or MDE.

If an individual is 18-21 and they are still in school and do not wish to explore, pursue, obtain or maintain community employment, they will not have to complete a MDE.

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July 10, 2014 Page 6

To understand how the term employment1 is used in “My Declaration,” the CDP and the MDE, please refer to the definition of

an integrated employment setting from Executive Order 13-04:

A setting that allows an individual to interact with non-disabled persons in the employment setting. An integrated employment setting cannot be facility-based work in a sheltered workshop or non-work activities, such as Alternatives to Employment (ATE). An integrated employment setting is a typical work environment, including self-employment or small business models, in the community. An integrated employment setting can include a group enclave or mobile crew but must allow an individual to interact with non-disabled persons in the employment setting.

Funding Source:

This section is important because employment services are funded through the Comprehensive Waiver and Support Services

Waiver. Employment services are:

Employment Path Community: Services that provide learning and work experiences, where the individual can develop general, non-job-task-specific strengths and skills that contribute to employability in integrated employment.

Small Group Employment: Works with a group of 2-8 people with disabilities. Earns a wage. Discovery/Career Exploration: Developing a Discovery Profile.

Initial Job Coaching: May include short term supports needed to assist the individual. This is time-limited. Ongoing Job Coaching: Ongoing Job Coaching is designed to provide support needed to assist the individual in

maintaining the job long-term.

Employment Path Facility: Same as Employment Path Community, except services occur in a facility setting.

Job Development: is designed to obtain a job in an integrated employment setting in the general workforce for which an individual is compensated at or above the minimum wage, but ideally not less than the customary wage and level of benefits paid by the employer for the same or similar work performed by individuals without disabilities.

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July 10, 2014 Page 7 If an individual cannot receive services through either the Comprehensive Waiver or the Support Services Waiver, they will not be able to receive any ODDS-funded employment services. For people who cannot receive services through one of these waivers, theirSC or PA should refer them to other employment resources such as VR or their local Career Center.

The Individual’s Current Employment Status:

2A. Select the waiver-funded employment services the individual has participated infor the last 90 days – because of this, multiple selections may be made. If the individual is authorized for a service but does not currently participate in it, do not select it. For example, Sam is authorized to receive initial job coaching services through the waiver. However, because he is not yet employed, he has not yet used the service, so do not select individual supported employment. Please refer to the service descriptions above when selecting services.

2B. Pertains to people who are employed but do not use the applicable ODDS employment service for support in their job. 2C. For each service selected in 2A., provide the requested information. If the individual has received the same service from more than one provider during the last 90 days, please list those providers in the applicable row. Also, indicate if the individual continues to receive this service. For example, Joe received Employment Path Community from Sertoma from

9/1/14-10/1/14. However, he chose to discontinue receiving that service from Sertoma, and began receiving the service from Impact on 10/2. Please list the information for both providers in Employment Path Community category by adding another row. The only difference would be the dates of service and that in Sertoma’s row, you would check “no” in the last column. Please note, you are only listing both providers because Joe has received this service from both providers during the last 90 days. In 2D., make the appropriate choice. Here is a brief explanation of each service:

Day Support Activities Facility (also known as Non-Work Facility): Person is engaged in non-work activities in a facility setting. Please note that this service is not the same as “Employment Path Facility.”

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July 10, 2014 Page 8  Day Support Activities Community (also known as Non-Work Community): Same as above but in a community setting.

Neither of These Two Services: Person has not participated in either of these services in the last 90 days. For the services selected in 2D., list the requested information in the chart in 2E.

Employment/Career Development

This section consists of a number of choices that are designed so the individual may clearly communicate what they want to happen in regard to Employment/Career Development for their Individual Support Plan (ISP) year. It is critical that the individual understands that what they select in this section will be the basis for their employment-related supports for the upcoming ISP year. An individual may request a CDP at any time – they do not have to wait for their annual ISP meeting to

create or update their CDP. Additionally, per Executive Order 13-04, “The provision of Employment Services by ODDS will not

be delayed or denied due to the lack of a Career Development Plan.”

A Note about Age: Some people exit high school prior to age 20 while others exit at 22. The employment /career

development section is divided into two categories, each with their own age criteria. However, as stated in “My Declaration”,

there are exceptions to the age criteria. If someone attends high school and they are 21 or 22 years old, select the “Transition Age Student” category. In contrast, if an individual is 18 and has exited high school, select the “Working Age Adults” category.  Students (age 18-20)

o Students: More information on when funding from ODDS can be accessed for students who are 18 and over and who are still in school is in Policy Transmittal APD-PT-13-016 (Comprehensive Services) or APD-PT-13-011 (Brokerage).

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July 10, 2014 Page 9

o Students who are 18 and over and still in school: If a student chooses to work, complete a CDP. If they choose not to work, nothing is required at this time, until they exit school. Within a year of exiting school a “My Declaration” and CDP or MDE must be completed.

Working age adults (21-60) who complete the “My Declaration” must choose one of the following statements: Employed in integrated employment setting and wants to: If chosen, then select the applicable sub-choice (s). The individual can make multiple selections of the sub-choices. Complete a CDP.

People who do not have an integrated job may choose from the following options:

o Currently unemployed and wants integrated employment: The person is unemployed and knows that they want integrated employment. Complete a CDP.

o Currently unemployed and interested in integrated employment: The person is unemployed and is interested in integrated employment. Complete a CDP.

o Not interested in integrated employment but may be interested in the future: The person does not have an integrated job and is not interested in competitive employment now but may be in the future. Complete a CDP.

o Currently unemployed and wants to retire: This selection can only be made if the person is 60 or older or will be 60 in this ISP year. Do not complete a CDP.

o Not interested in integrated employment now and not interested in integrated employment in the future: If the person does not intend to be employed this ISP year and in the future, this must be selected. Complete a MDE.

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