Your Name: Melissa Jones Name of Services Coordinator (SC) or Personal Agent (PA): Charlie Henry My Annual Declaration of My Employment Goals for My ISP Year Date of Birth: 7-5-1970 Phone #/Email Address: 503-123-4567; mjones@yahoo.com SC/PA Phone # and Email Address: 503-423-4567; Charlie.H@yahoo.com Today s Date: 6-9-14 Name of Brokerage or CDDP: Choices Brokerage 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 Discovery/Career Exploration Are You Still Receiving this Service? Yes No July 10, 2014 Page 1
My Annual Declaration of My Employment Goals for My ISP Year Job Coaching Yes No Small Group Employment Employment Path Community Employment Path Facility Yes No Yes No 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 Emerald Services, Salem, Oregon Anna Howard, AnnaH@Emerald.org 503-987-6543 Yes No Day Support Activities Facility Yes No July 10, 2014 Page 2
3. Your employment goals for your upcoming ISP year: My Annual Declaration of My Employment Goals for My 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: Development Plan and Vocational Assessment (CDP) will be completed: Date by which a Career 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 ISP Year. July 10, 2014 Page 3
4: People who helped me to create My Declaration : My Annual Declaration of My Employment Goals for My ISP Year 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 Melissa Jones (Each person would sign their name in this column) Self 503-123-4567 mjones@yahoo.com Sue and Joe Jones Parents 503-446-9876 JJones@yahoo.com Anna Howard Day Supports Coordinator Emerald Services 503-987-6543 AnnaH@emerald.org Charlie Henry Personal Agent Choices Brokerage 503-423-4567 Charlie.H@yahoo.com X Pe rso n (Melissa would sign her name) July 10, 2014 Page 4
My Name: Melissa Jones Name of My Services Coordinator (SC) or Personal Agent (PA): Charlie Henry Date of Birth: Today s Date: 7-5-1970 6-9 - 14 Name of Brokerage or CDDP: Choices Brokerage SC or PA Phone # & Email: 503-423-4567 Charlie.H@yahoo.com 1) Do you believe that you can work now? Yes No 2) Do you believe that you can work in the future? Yes No 3) If the answer was no to #1 and/or #2, please explain why you do not believe you can work now or in the future: I have cancer and have been given 7 months to live. 4) Do you want to work now? Yes No 5) Do you want to work in the future? Yes No 6) If the answer was no to #4 and/or #5, please explain why you do not want to work now and/or in the future: July 10, 2014-Page 5
7) A goal of the Employment First initiative is to encourage individuals to pursue integrated employment and to help them find integrated employment. Would you like to work in integrated employment, sometimes called a community job? Would you like to learn more about integrated employment? If you answered yes to one or both of these questions, do not finish completing the MDE, instead, please complete a Career Development Plan. If the answer is no to BOTH of these questions, please explain why you have chosen not to explore, pursue, obtain or maintain integrated employment now or in the future. I have been told that I have 7 months to live 8) On this chart, identify what would help you to pursue employment. At least one area (A-G) must be checked. To pursue employment, I need help in these areas: Use this space to record notes, thoughts or actions to be taken A. Transportation to and from work Check the strategies that could help you with this: 1. Getting a job within walking/rolling distance of my home 2. Using public transportation 3. Asking friends, family or co-workers for a ride 4. Getting a job on the bus line 5. Moving to an a home that is on or near a bus line 6. Asking my residential provider to get me to work 7. Requesting Transportation Through The K-Plan 8. Other, please specify: July 10, 2014-Page 6
B. Matching my skills, interest and abilities to a job: Some examples are: I don t know of any jobs that interest me; I had a bad experience with a job; I don t know what I am good at; The jobs I have had were tough for me to do. Check the strategies that could help you with this: 1. Visiting my career center to learn about jobs in my community. 2. Requesting ODDS Discovery/Career Exploration 3 Requesting ODDS Employment Path Services 4. Job shadowing a friend or family member 5. Talking with my friends/ family about their jobs 6. Analyzing what contributed to having a bad job experience 7. Talking to people who have disabilities who work to find out about their employment experience 8. Other, please specify: C. Fear that I will lose my Social Security Disability and/or Medicaid benefits. Check the strategies that could help you with this: 1. Scheduling an appointment with a benefits specialist who works for VR or Disability Rights Oregon. 2. Other, please specify: D. I have some challenges with my behavior. Check the strategies that could help you with this: 1. Discussing Employment First and its key beliefs,including that everyone (including people who may be labeled as having behavioral issues) is ready and able to work. July 10, 2014-Page 7
2. Requesting behavior support services 3. Requesting ODDS Discovery/Career Exploration 4 Requesting ODDS Employment Path Services 5. Discussing work with my behavior support professional 6. Talking with my friends and/ or family about their jobs 7. Other, please specify: E. I have significant health problems and/or health related needs: Check the strategies that could help you to be employed: 1. My health problems are temporary and I am undergoing treatment to get better examples are chemotherapy, recovering from surgery, etc. 2. A job would need to meet certain criteria for my health, examples are: need to work inside, I have allergies, etc. 3. I need a job with a schedule that will not interfere with reoccurring medical appointments such as dialysis, etc. 4. Due to my health problems, I get tired after a few hours. Examples of solutions are working part-time, etc. 5. Because I have health-related needs through the day (examples are: help with using the restroom, eating, etc.) if I worked, I would need help with these activities. 6. Other, please specify: I have been given 7 months to live. I have been given 7 months to live. July 10, 2014-Page 8
F. I really like the people, places and things I do now and am reluctant to change my routine: Examples are: I enjoy the sheltered workshop and am worried that I won t get to see my friends as much as I want to if I get a community job; I and/or my team are concerned that it will be hard to make friends at work; I and/or my team are concerned that I will not succeed at work; I and/or my team do not think that I am ready to work now or in the future. Check the strategies that could help you with this: 1. Discussing Employment First and its key beliefs including that everyone is ready and able to work. 2. To schedule activities with friends when I don t work 3. To think about how I have made friends in the past 4. Job Shadowing with family and/or friends 5. Talking with my friends/ family about their jobs 6. Visiting my career center to learn about jobs in my community 7. To begin working only a few hours a week 8. Requesting ODDS Discovery/Career Exploration 9. Requesting ODDS Employment Path Services 10. Other, please specify: G. Nothing could make me change my mind about not wanting to work for my upcoming ISP year: If you want to supplement your answers to questions 3 and/or 6 please share it in the space below. July 10, 2014-Page 9
9) If there is additional information you would like share about your decision not to explore, pursue, obtain or maintain community employment for your upcoming ISP year or in the future, please share it in the space below. 10) People who helped me to create and/or decide on my employment goals: Please type or clearly print this information. 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 Melissa Jones (Each person would sign their name) Self 503-123-4567 mjones@yahoo.com Sue and Joe Jones Parents 503-446-9876 JJones@yahoo.com Anna Howard Day Supports Coordinator Emerald Services 503-987-6543 AnnaH@emerald.org Charlie Henry Personal Agent Choices Brokerage 503-423-456Charlie.H@yahoo.com July 10, 2014-Page 10
This document is accurate and reflects my desire not to explore, pursue, obtain or maintain community employment for my upcoming ISP year and in the future. I understand that I am free to change my mind about this decision at any time during the next twelve months. I also understand that by making this choice, I will not be able to receive any waiver-funded employment services, unless I change my mind and decide to explore, pursue, obtain or maintain community employment. X Pe rson (Melissa would sign her name.) July 10, 2014-Page 11