DADS or HHSC Form - The Texas Department of Aging and ...

Form 3596
Page 8, 12-2013
IV. Individual’s CLASS Habilitation Schedule
Special Instructions
Schedule 1.
Type of Service Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Schedule 2.
Weekly Total Habilitation Hours:
Type of Service Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Weekly Total Habilitation Hours:
Totals Reflected on IPC
Number of Covered Weeks Weekly Total Hours Annual Total Cost
Service Schedule 1 Schedule 2 Schedule 1 Schedule 2 Schedule 1 Schedule 2
Habilitation Attendant (SVC 10/CDS SVC 10V)
Habilitation Training (SVC 10/CDS SVC 10V)
DSA Representation (SVC 10)
Habilitation Delegated Tasks (SVC 10A)
Annual Total Habilitation Hours:
Number of Covered Weeks Weekly Total Hours Annual Total Cost
Service Schedule 1 Schedule 2 Schedule 1 Schedule 2 Schedule 1 Schedule 2
Prevocational Services (SVC 10B)
Supported Employment (SVC 37 CDS SVC
37V)
Employment Assistance (SVC 54)
Annual Total Cost: $
I agree to the above schedule and understand that I cannot exceed the number of approved hours within any given week as shown above. To accommodate
unforeseen circumstances and to provide for flexibility in scheduling, I agree to notify the DSA within an acceptable time frame, preferably five working days,
of any changes I wish made to make to this schedule.
Signature – Individual/LAR Date Signature – Case Manager Date
Signature – DSA Representative Date Signature – SPT Member Date
Signature – SPT Member Date Signature – SPT Member Date