Consumer Name
IRIS Identification Number
Elmer Dairy
000000000
WI Division of Vocational Rehabilitation
Department of Workforce Development
INDIVIDUALIZED PLAN for EMPLOYMENT (IPE)
Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04 (1)(m)].
CHECK ONE:
IPE
IPE AMENDMENT
MY LONG-TERM EMPLOYMENT GOAL IS:
Dairy farming.
THE DATE THAT I WILL REACH MY GOAL:
6 – 9 months from now.
SERVICES
START
DATE
END
DATE
PROVIDERS
WHO
PAYS
PAYMENT
METHODS
Primary: REHABILITATION TECHNOLOGY
1. Tractor steps and handrail
For 4020 J. Deere
4/03
6/03
Central Coop
DVR
PO
2. High back air ride seat for
4020 and 4010 and David
Brown-1200.
4/03
6/03
Central Coop
DVR
PO
4/03
6/03
County Equip
DVR
PO
4/03
6/03
Upper Body
DVR
PO
5. Fabricated steps onto loader 4/03
And frame.
6/03
Ben Fab
DVR
PO
6. Agramatic hitches
4/03
6/03
Ralph Mfg Inc
DVR
PO
7. John Deere 4 X 2 Gator
4/03
6/03
Power Package
DVR
PO
3.
Bushel poly – 24” wheel
Cart.
4. Upper hand universal
Handles
Secondary:
Secondary:
My progress will be measured by (include checkpoint dates):
My ability to maintain farm operation and use the equipment that is purchased to continue my
dairy farming will be used to assess progress.
Consumer Name
IRIS Identification Number
Elmer Dairy
SERVICES
Primary:
000000000
START
DATE
END
DATE
PROVIDERS
WHO
PAYS
METHODS
04/03
08/03
DVR
DVR
In house
service
04/03
08/03
DVR
DVR
In house
service
Vocational Counseling and Guidance
to address my role as an employer of
agricultural workers
Secondary: Transportation mileage
PAYMENT
reimbursement
Secondary:
My progress will be measured by (include checkpoint dates):
Guidance and Counseling is being given to address my new role as an employer, as I will be hiring workers to take
on some of the physical jobs I can not due as efficiently and quickly. I will keep our regularly scheduled
appointments and report at least 1 time per month on the relationship I have developed with my employees.
Primary:
04/03
06/03
Numeric Accounting DVR
Purchase order
Services
Accounting consultation and record
keeping set up
Secondary:
Secondary:
My progress will be measured by (include checkpoint dates):
My progress will be measured by my ability to independently maintain the employer/employee records needed for
my business. A completed record system developed by my accountant will allow me to keep those records
required for taxes and other reporting needs.
Primary:
04/03
06/03
River Valley
DVR
Purchase Order
Technical
College
Computer training on Quicken
Secondary: Transportation mileage to
and from class
04/03
06/03
Myself
DVR
Direct Pay
Secondary:
My progress will be measured by (include checkpoint dates):
My ability to use my computer to keep necessary records will be used to assess my progress along with the
mileage log I will provide DVR to show my attendance in the class. My completion certificate will also be used to
show my progress.
Primary:
Secondary:
Secondary:
My progress will be measured by (include checkpoint dates):
Consumer Name
IRIS Identification Number
Elmer Dairy
000000000
I WILL BE RESPONSIBLE FOR:
Notifying DVR of receipt of goods, equipment and approving quality. Assure DVR that
accommodations help. Complete mileage log month if I use DVR transportation services. Attend
class and do my best. Participate in vocational counseling with my counselor and listen and use
ideas that are appropriate. Provide DVR with my certificate of completion for the Quicken class.
Notify DVR when I have my accounting consultation completed. Demonstrate my knowledge by
bringing in a monthly record I have kept on employee costs, etc.
DVR WILL BE RESPONSIBLE FOR:
Pay for services as agreed. Be available to provide counseling and guidance. Refer to outside
resources as appropriate.
I have been offered the choice to develop my own plan:
I have been offered assistance in creating my employment plan:
I have been given choices to assist me in creating my employment plan:
I have received a copy of my individual rights:
Yes
Yes
Yes
Yes
No
No
No
No
For people receiving Social Security or SSI payments for reasons of disability:
I understand that my signature on this Plan for Employment Form also indicates that I am
assigning my Social Security ticket to work to the Wisconsin Division of Vocational
Rehabilitation and designating them as my employment network. Since activation of the ticket
to work allows two years of exclusion from continuing disability reviews (provided the review
process has not already started), I may activate the ticket at a later date if my plan for
employment is expected to exceed two years in duration. If I elect that option of delayed
activation, I have written the date the ticket is to be activated on the plan.
Signature (Consumer Representative Signature, If Appropriate)
Date Signed
Counselor Signature
Date Signed
Review Signatures
Signature (Consumer Representative Signature, If Appropriate)
Date Signed
Counselor Signature
Date Signed
Signature (Consumer Representative Signature, If Appropriate)
Date Signed
Counselor Signature
Date Signed
Consumer Name
Elmer Dairy
IRIS Identification Number
000000000
Signature (Consumer Representative Signature, If Appropriate)
Date Signed
Counselor Signature
Date Signed
DVR-12726 (R. 03/2003)