Vocational Rehabilitation Services Manual D-300: Records Management

CFR §361.47 Record of services.

(a) The designated State unit must maintain for each applicant and eligible individual a record of services that includes, to the extent pertinent, the following documentation:

(1) If an applicant has been determined to be an eligible individual, documentation supporting that determination in accordance with the requirements under §361.42.

(2) If an applicant or eligible individual receiving services under an individualized plan for employment has been determined to be ineligible, documentation supporting that determination in accordance with the requirements under §361.43.

(3) Documentation that describes the justification for closing an applicant's or eligible individual's record of services if that closure is based on reasons other than ineligibility, including, as appropriate, documentation indicating that the State unit has satisfied the requirements in §361.44.

(4) If an individual has been determined to be an individual with a significant disability or an individual with a most significant disability, documentation supporting that determination.

(5) If an individual with a significant disability requires an exploration of abilities, capabilities, and capacity to perform in realistic work situations through the use of trial work experiences to determine whether the individual is an eligible individual, documentation supporting the need for, and the plan relating to, that exploration and documentation regarding the periodic assessments carried out during the trial work experiences in accordance with the requirements under §361.42(e).

(6) The individualized plan for employment, and any amendments to the individualized plan for employment, consistent with the requirements under §361.46.

(7) Documentation describing the extent to which the applicant or eligible individual exercised informed choice regarding the provision of assessment services and the extent to which the eligible individual exercised informed choice in the development of the individualized plan for employment with respect to the selection of the specific employment outcome, the specific vocational rehabilitation services needed to achieve the employment outcome, the entity to provide the services, the employment setting, the settings in which the services will be provided, and the methods to procure the services.

(8) In the event that an individual's individualized plan for employment provides for vocational rehabilitation services in a non-integrated setting, a justification to support the need for the non-integrated setting.

(9) In the event that an individual obtains competitive employment, verification that the individual is compensated at or above the minimum wage and that the individual's wage and level of benefits are not less than that customarily paid by the employer for the same or similar work performed by non-disabled individuals in accordance with §361.5(c)(9)(i).

(10) In the event an individual achieves an employment outcome in which the individual is compensated in accordance with section 14(c) of the Fair Labor Standards Act or the designated State unit closes the record of services of an individual in extended employment on the basis that the individual is unable to achieve an employment outcome consistent with §361.5(c)(15) or that an eligible individual through informed choice chooses to remain in extended employment, documentation of the results of the semi-annual and annual reviews required under §361.55, of the individual's input into those reviews, and of the individual's or, if appropriate, the individual's representative's acknowledgment that those reviews were conducted.

(11) Documentation concerning any action or decision resulting from a request by an individual under §361.57 for a review of determinations made by designated State unit personnel.

(12) In the event that an applicant or eligible individual requests under §361.38(c)(4) that documentation in the record of services be amended and the documentation is not amended, documentation of the request.

(13) In the event an individual is referred to another program through the State unit's information and referral system under §361.37, including other components of the statewide workforce development system, documentation on the nature and scope of services provided by the designated State unit to the individual and on the referral itself, consistent with the requirements of §361.37.

(14) In the event an individual's record of service is closed under §361.56, documentation that demonstrates the services provided under the individual's individualized plan for employment contributed to the achievement of the employment outcome.

(15) In the event an individual's record of service is closed under §361.56, documentation verifying that the provisions of §361.56 have been satisfied.

(b) The State unit, in consultation with the State Rehabilitation Council if the State has a Council, must determine the type of documentation that the State unit must maintain for each applicant and eligible individual in order to meet the requirements in paragraph (a) of this section.

(Authority: Sections 12(c), 101(a)(6), (9), (14), and (20) and 102(a), (b), and (d) of the Rehabilitation Act of 1973, as amended; 29 USC 709(c), 721(a)(6), (9), (14), and (20), and 722(a), (b), and (d))

The case file system consists of an electronic case file and paper case file.

The purpose of this section is to describe processes necessary for paper case file uniformity. The VR staff is ultimately responsible for the:

• management of the caseload;
• location of case files; and
• case correction activities.

VR staff must:

• secure all documents from the customer case file to the file jacket;
• record the customer's last name and first name (for example, García, Isabella A.) and case ID on the tab label of each case file jacket;
• stamp "Confidential" on the front and back of the case file jacket;
• ensure that all documents are date-stamped or otherwise marked with the date that the document is generated and/or received in the office; and
• date-stamp the first and last pages of the packets for documents containing many pages (such as packets of medical records).

D-303-1: Case Files

Documentation of service delivery, including contact reports and other reports, are maintained in either a virtual case file or a two- or six-sided paper case file.

Any electronic documents that are not contained in RHW are contained virtually in a shared drive such as the Unit G: Drive, SharePoint, OneDrive, etc. RHW must be updated to indicate the status of the case file as either:

• Virtual – all documents are stored electronically,
• Paper – all documents are stored in a paper case file, or
• Mixed – some documents are stored electronically and in a paper case file.

Documentation Order

Each region may determine which type of paper case file is used. In either case, the following documentation order must be maintained, two- or six-sided. Each section of the case file should be organized so that initial documents are on the bottom and most recent are on the top unless otherwise specified. Because of the volume of information often contained in the six-sided case file, dividers should be used to section off certain areas of documentation. This makes the information easier to access on a routine basis.

Two-Sided Case File

The VR staff files the following documents from bottom to top on the left side of the case file in the order received, making sure that all financial documents are grouped together, including:

• invoices;
• bidding documentation;
• signed itemized receipts;
• all service authorizations;
• correspondence with providers regarding billing; and
• all other documents related to customer purchases.

The VR staff then files the following documents from bottom to top on the right side of the case file in the order received, as follows:

• Signed release forms;
• Signed paper individualized plan for employment (IPE) or IPE amendments;
• Correspondence;
• All relevant records and reports and assessments;
• Copies of documents verifying the customer's identity and authorization for employment in the United States;
• Financial records used to verify customer income and expenses for calculating participation in cost of services;
• Verification of eligibility for Social Security Income/Social Security Disability Income benefits; and
• All other documents related to the customer's VR program.

Six-Sided Case File—Vocational Rehabilitation

Side 1: Basic information is placed in the following order from bottom to top, chronologically (most recent on top), and separated by a divider:

• Old contact reports (CB-4) in chronological order, most recent on top, documenting activity from intake through closure and, if necessary, post-employment
• If paper application is taken, VR5056, Application for Vocational Rehabilitation Services; pseudo PIN is used in ReHabWorks (RHW)
• VR5060, Permission to Collect Information (optional)
• VR5061, Notice and Consent for Disclosure of Personal Information
• VR1390, Checklist for Determining Significance of Disability (if used)
• VR5163, Individualized Plan for Employment (IPE) and VR5159, Individualized Plan for Employment (IPE) Amendment; entered in RHW using a pseudo PIN
• Customer Data Sheet (CDS) or Initial Contact Page from RHW (optional)
• Any other document that is signed with a pen, ink signature, or digital signature that is later entered in RHW using a pseudo PIN
• Copies of the customer's driver's license or ID card, and health insurance card(s)

Side 2: Medical information. All reports relating to medical information—for example, eye examination results, physician notes, general physical examination, low-vision reports, and psychological reports—are placed in chronological order from top to bottom, most recent on top, and separated by a divider.

Side 3: Assessments are placed in the following order from top to bottom, chronologically, and separated by dividers:

• Diabetic service reports, including evaluation and training;
• Orientation and Mobility reports, including evaluation and training reports; and
• Copies of past admissions, review, and dismissals (ARDs) if side four is full. (These should be at the bottom of side three using a tab to separate from other items.)

Side 4: Educational and vocational information is placed in the following order from top to bottom, chronologically, and separated by a divider. (For vocational service information, each service type is separated by a divider.):

• Vocational evaluation or training reports;
• Academic-related reports, for example, exemption from payment of tuition, copies of grades, class schedules;
• On-the-job training reports, job development, and job placement reports; and
• For Transition cases, copies of the child's ARD, Individualized Education Program, individualized treatment plan, and/or individualized family service plan (updated at a minimum every three years).

Note: Once side four is full of ARD paperwork, then older ARDs are moved to the bottom of side three; only the most current ARDs remain on side four.

Side 5: Documentation of equipment purchases and general correspondence are placed in the following order from top to bottom, chronologically, and separated by a divider:

• All documentation related to equipment purchases (that is, purchase packets, equipment receipts, the VR2014, Rehabilitation Equipment Receipt and Agreement); and
• General correspondence, including letters to and from family, letters to and from vendors, and Social Security packets.

Note: Flyers and other mail-outs to customers do not have to be printed and placed in the case file. A scanned copy of a mail-out can be pasted in case notes, or a brief case note can be entered summarizing a mail-out.

Side 6: Service authorizations (SA) and invoices with references to SAs are placed in chronological order with the most recent on top and separated by a divider.

Note: A paper copy of the SA is required in the case file. Case file copies of requisitions and vouchers should have a copy of the invoice and/or reader service statement attached before filing. SA numbers must be written on invoices.

Second Case File

When the volume of information on a customer is more than a single case file can physically hold, a second case file can be used.

The following information must be transferred to the second case file:

• Medical release forms
• The most current IPE
• The most current eye report
• All documentation necessary for the current management of a case

As a rule, the original case file should retain extensive past training reports and pertinent information regarding customer purchases.

Case Files for Potentially Eligible Students

A paper and/or virtual case file is required for each potentially eligible student. The case file for a potentially eligible student must include:

• the VR1820, Request to Receive Pre-Employment Transition Services;
• documentation verifying the student’s disability;
• any release forms;
• any referral forms, reports, invoices, and relevant documentation related to Pre-ETS; and
• documentation of legal status to work in the United States. (Note: This documentation is required only when a potentially eligible student is participating in a work placement as part of work-based learning.)

When closing a potentially eligible student’s case, VR staff must follow the policy in this chapter related to closing the paper case file.

Maintaining Closed Case Files

Keep all documents, including financial records, in the closed customer virtual and/or paper case file, which is stored for a total of seven years.

Field offices only store files for cases closed in the current and preceding fiscal year.

Ship all other closed customer paper case files to the Texas Workforce Commission (TWC) Records Management Center (RMC) in accordance with procedures in the TWC Records and Information Management Manual, Records Storage (PDF).

Retrieve closed customer paper case files from the TWC RMC in accordance with TWC Records and Information Management Manual, Records Storage.

Reopening a Case

When starting a new file on a case that was previously active, the VR staff copies or downloads significant documents from the closed case file for placement in the new file. Do not remove forms, reports, and other data from the old file.

D-303-2: Records and Reports from Outside Sources

Records and reports that are received from other sources, such as medical providers or training institutions, must be reviewed by the VR counselor before they are filed in the customer's paper or virtual case file. The VR counselor initials and dates next to each date stamp to confirm that they have reviewed the content.

With the exception of the required date stamps and VR counselor date and initials to confirm review of content, VR staff should avoid making permanent marks on records and reports that are received from sources outside of VR. The use of a yellow highlighter to draw attention to specific content is acceptable.

Computerized Criminal History (CCH) records are not to be added to a customer’s virtual case file under any circumstances. For information on storing these records, refer to VRSM B-405-4: Evaluating and Documenting Computerized Criminal History Results.

Content that is not relevant to the customer's VR services should not be maintained in the customer's virtual or paper case file. When content is received that is not relevant to the customer's VR case, this information should be disposed of by the VR counselor.

For information on the confidentiality, use, and sharing of customer records, see VRSM A-207: Confidentiality and Use of Customer Records and Information.

At the end of the fiscal year, closed customer case files from the previous fiscal year are boxed, sent, and stored at the TWC Records Management Center (RMC).

Each office is responsible for completing an Inventory and Transmittal Spreadsheet; staff must request blank spreadsheets from Claimant Files (claimant.files@twc.texas.gov). Completed spreadsheets are emailed to Claimant Files. VR staff box and ship the closed customer case files to the RMC.

D-307-1: Pulling Closed Case Files for Storage

For each case file on the inventory sheet that is pulled for storage, VR staff should:

• Remove the sealed Computerized Criminal History (CCH) report from the paper case file. Write the customer's last name, first initial, and case ID on the confidential envelope. Place the envelope in a separate box bound for RMC for storage.
• Print any necessary records stored on CD and file the copies in the paper case file. Remove the CD from the case file and place it in the locked confidential shredding container.
• Secure any loose papers to the file prongs and remove staples, clips and post-it notes from the entire file. Small sheets of paper must be copied to a standard 8 1/2 by 11-inch letter size paper.
• Documents in six-sided files must be taken out and put into a regular two-sided file.
• Envelopes, with the exclusion of the sealed CCH envelopes, must be opened and the documents removed from the envelope. If the documents are folded, they must lay flat in the file.
• Record on the tab label the customer's last name, first name, and case ID.
• Stamp "Confidential" on the front and back of each file.
• Using a black felt-tip marker, write the fiscal year in which the case was closed on the outside of the file jacket.
• Change the file location status in ReHabWorks to Records Center.

D-307-2: Adding Files to Boxes

When adding the closed customer files to boxes to be shipped, VR staff ensure that:

• Each box must contain only the closed case files from the previous fiscal year.
• There is approximately 2" of space in each box in case of interfiles. (Boxes are not over packed.)
• Only standard records storage boxes are used (hand-holds on either end, with a removable lid, 10" x 12" x 15"). Do not use copy paper boxes.
• Files are arranged within the box in alphabetical order by last name.
• Only ten boxes are sent to RMC per shipment.
• Each box is labeled with "Box [number]" on the left side of the hand hold. Underneath the "Box [number]" the label must contain the "Cost Center [number]" and "Location Code [number]." The box lid should not cover the box number.

D-307-3: Completing the Box Inventory Spreadsheet

All files in each box must be listed on the Box Inventory Spreadsheet. Ten boxes are sent per shipment ro RMC. To complete a Box Inventory Spreadsheet, update the fields "box_nbr" and "rhw_updated" for each file on your TWC Inventory Spreadsheet as follows:

• For "box_nbr", number each box in the set as "[department cost center number]-001", "[department cost center number]-002", etc. (for example, 4584-001).
• For "rhw_updated", put "Yes" after ReHabWorks has been updated to reflect the new location of that file.
• All the fields on this tab are mandatory:
  • Once the inventory is complete, VR staff filter the "box_nbr" field for each box and print the inventory sheet.
  • A hard copy is placed in front of the first file of the corresponding box. One is kept for the unit reference.

D-307-4: Completing the Transmittal Spreadsheet

Once VR staff have completed the file inventory, a Transmittal Spreadsheet for all the files will need to be completed.

For each line of the transmittal, VR staff will list information about one box within the batch:

• Customer Box Number (4-digit cost center and box number)
• Major and Minor Description (Major description example: FY'20 closed customer case files.) (Leave Minor description blank.)
• Alpha FROM and TO (this is the last name of the first customer in box and last name of the last customer in the box)
• Destruction Date (The close date of the fiscal year plus seven years. Example: For FY'20, this will be 8/31/2027.)
• Date FROM and TO (Example: From date: Beginning of fiscal year. For FY'20, this would be 9/1/19. To date: End of fiscal year. For FY'20, this would be 8/31/20.)

D-307-5: Preparing Computerized Criminal History in Closed Case Files

All Computerized Criminal History (CCH) records from the previous fiscal year are stored in a separate box.

• CCHs must be in a sealed confidential envelope.
• Envelopes are arranged within the box in alphabetical order by last name.
• A separate Box Inventory Spreadsheet and Transmittal Spreadsheet is completed for CCHs.

Each box is labeled with the Region number, Unit name, and "Confidential CCH Records" on the left side of the hand hold and the top of the box.

D-307-6: Requesting Pickup

VR staff email both the File Inventory and Transmittals worksheets in Excel format to claimant.files@twc.texas.gov for approval and upload.

The following information is included in the email:

• On the subject line: Cost Center number, FY 20__ Closed Customer Case, City of Field Office
• Contact information (Contact Name and Phone number)
• Physical pickup location (street address, room or suite number, city, state, ZIP code)
• Special instructions for location access, if any
• Number of boxes you are requesting to have picked up (no more than 10 per shipment)

A separate email is sent for CCH records. The following information is included in the email message:

• On the subject line: CCH files
• Contact information (Contact Name and Phone number)
• Physical pickup location (street address, room or suite number, city, state, ZIP code)
• Special instructions for location access, if any
• Number of boxes you are requesting to have picked up.

VR staff should double-tape all boxes (not covering the hand-holds) to secure the lids to the boxes and ensure that no records spill out during transit.

TWC RMC staff will review the inventory and transmittals sheets for approval. Within five business days upon approval from the RMC, the field office will schedule the shipment of file boxes on the approved inventory worksheets to the address below:

Texas Workforce Commission
Records Management Center
4405 Springdale Road Suite C
Austin, TX 78723

Once records are sent through FedEx, VR Staff must email all FedEx tracking numbers to claimant.files@twc.texas.gov on the day the records are picked up by FedEx.

TWC Records Management Center (RMC) staff will confirm the receipt of the records by notifying the VR staff member who submitted the tracking numbers once the shipment is received at TWC RMC. If VR Staff have not received the confirmation that the shipment has arrived to TWC RMC within 3 business days of the expected delivery date, VR Staff will email  claimant.files@twc.texas.gov to coordinate follow up with FedEx.

Once the shipment has been received by RMC, staff may ship any additional boxes following procedures outlined in this chapter refer to D-307: Processing Closed Case Files.

Field office staff will need to determine the supplies needed for shipping the files and coordinate with the third-party shipping vendor.

Effective September 1, 2018, the TWC express shipping provider is FedEx. Please refer to the TWC Mail Services Instructions (PDF) (https://intra.twc.texas.gov/intranet/phss/docs/mail_services_instructions.pdf) for further information on shipping using FedEx.

When using a third-party shipping service, the TWC EMA-65 Express Mail Authorization form must be completed and emailed only to Alisha.Lewis@twc.texas.gov. When emailing the EMA-65 Express Mail Authorization form, do not attach or include the Inventory and Transmittal spreadsheet.

VR staff must:

• Ensure personally identifiable information (PII) is not exposed.
• Make sure that all boxes are double-taped (not covering the hand-holds) to ensure that no records will spill during transit.
• Save file inventories in a secure place.