Support Costs Sample Form

Student's Name: Jane Doe
Date of Plan: 3/03/04

What does the student need?

Who can meet that need?

How much will it cost?

Who will fund?

Next steps…

Vocational Profile

School

Teacher will write – 15 hours

School

Complete Discovery activities.

Conduct records review.

Development of two work experiences – 1 month each

ABC Employment Agency

10 hours at $50/hour = $500

Vocational Rehabilitation

Contact employers.

Develop Portfolio.

Wages for 2 work experiences – 40 hours each

ABC Employment Agency (with wages run through ACME Temp. Services)

$5.15/hr x 80 hours = $412

Vocational Rehabilitation

Complete required employment forms (for taxes, etc.).

Notify SSA that Jane will have earnings.

Transportation

Parent

Mom will transport – 40 total work days (2 hours/day) x 15 minutes roundtrip/day = 10 hours

Parent

Develop work schedule so parent knows when her services will be needed.

Job Coaching

School

Paraeducator will job coach – 30 hours

School

Conduct task and environmental analyses once sites have been established.

Complete discrepancy analyses once sites have been established.