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P. O. Box 944202
Sacramento, CA 94244-2020

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SEP/WAP Work Services Forms

These forms are to be used by work service (formerly Habilitation) providers and regional centers to process Work Services information. The Excel forms can be downloaded and completed using the Microsoft Excel spreadsheet program. The PDF instructions can be downloaded and printed using the free Adobe Acrobat Reader. For further information, please read the instructions accompanying each form.

Program Advisory: Student Eligibility for Habilitation Services for
DS 1964, DS 1971 & DS 1972

DS 1961 SEP - SEP/Individual Habilitation Services Plan
This form is the standardized service plan Supported Employment Program (SEP). Providers use to implement the consumer's vocational goals of the Individual Program Plan (IPP).
Users: SEP service providers.

DS 1961 SEP (7/04) (Excel)
Instructions (PDF)

DS 1961 WAP - WAP/Individual Habilitation Services Plan
This form is the standardized service plan Work Activity Program (WAP). Providers use to implement the consumer's vocational goals of the Individual Program Plan (IPP).
Users: WAP service providers.

DS 1961 WAP (7/04) (Excel)
Instructions (PDF)

DS 1962 - Request For New SEP Groups
A Supported Employment Program-Group Placement (SEP-GP) approval request is submitted by service providers to DDS to obtain approval of new SEP Groups.
Users: SEP-GP service providers.

DS 1962 (1/2005) (Excel)
Instructions (8/2012) Updated Information(PDF)
DS 1962/Supplemental Narrative Summary Guidance Template (8/2012) (Excel) New Information

DS 1963 - Request For Approval Of SEP Group Changes
This form is submitted by service providers to request changes in a specific approved supported employment program group.
Users: SEP-GP service providers.

DS 1963 (1/2005) (Excel)
Instructions (PDF)

DS 1964 - Supported Employment Group Billing and Attendance Form
This form must be completed as an excel file, password protected and submitted to regional centers, DOR and DDS monthly. After downloading the file, enter the vendor information at the top of the form and consumer and job coach information up to the "Funded By" column. Save a copy of this file as a "master". Should any problem arise with the form, the "master" is available to start over.

DS 1964 (02/2011) (Excel)
Macro Instructions (PDF)

DS 1968 - Vocational Rehabilitation Referral
This form is used to refer consumers to the Department of Rehabilitation for Vocational Rehabilitation Services.
Users: Regional Center Service Coordinators.

DS 1968 (4/04) (Excel)
Instructions (PDF)

DS 1969 - Vocational Services Exit Report
This form is completed when a consumer exits a habilitation services program.
Users: Regional Center Service Coordinators and Habilitation Services Providers.

DS 1969 (4/04) (Excel)
Instructions (PDF)

DS 1970 SEP-IP - SEP-IP/Habilitation Services Vendor Profile
This form is used to briefly describe the services, staff and philosophy of the Supported Employment Program-Individual Placement (SEP-IP) service provider's program.
Users: SEP-IP Services Providers.

DS 1970 SEP IP (4/04) (Excel)
Instructions (PDF)

DS 1970 SEP-GP - SEP-GP/Habilitation Services Vendor Profile
This form is used to briefly describe the services, staff and philosophy of the Supported Employment Program-Individual Placement (SEP-GP) service provider's program.
Users: SEP-IP Services Providers.

DS 1970 SEP GP (4/04) (Excel)
Instructions (PDF)

DS 1970 WAP - WAP/Habilitation Services Vendor Profile
This form is used to briefly describe the services, staff and philosophy of the Work Activity Program- service provider's program.
Users: WAP Services Providers.

DS 1970 WAP (4/04) (Excel)
Instructions (PDF)

DS 1971 WAP - WAP/Work Activity Program Consumer Monthly Report

Outcome data for consumers provided Work Activity Program services is documented on this form.
Users: WAP Services Providers; Regional Center can preload consumer names and identification numbers.

DS 1971 WAP (7/2006) (Excel)
Instructions (PDF)

DS 1972 SEP IP - SEP/Supported Employment Individual Placement Consumer Monthly Report
Outcome data for consumers provided Supported Employment Program- Individual Placement services is documented on this form.
Users: SEP Services Providers; Regional Center can preload consumer names and identification numbers.

DS 1972 SEP IP (7/2006) (Excel)
Instructions (PDF)

If you have any questions regarding these forms, please send an e-mail to
work.services@dds.ca.gov.

 
 
Last Updated: 8/14/2012