Form 1583, Employee Qualification Requirements

Instructions

Updated: 4/2012

Purpose

To provide information to the individual requesting services or the individual receiving ongoing services on additional responsibilities of being an employer in the Consumer Directed Services (CDS) option offered by their program, and who may or may not be hired in CDS.

Procedure

When to Prepare

Complete this form after the individual reviews Form 1581, Consumer Directed Services (CDS) Option Overview, and Form 1582, Consumer Directed Services Responsibilities, and elects to participate in CDS.

Number of Copies

One original and one copy.

Form Retention

Retain a copy of Form 1583 in the case folder.

Transmittal

After the information is reviewed, the case manager/service coordinator gives the original Form 1583 to the individual.

Detailed Instructions

The case manager/service coordinator reviews with the individual:

Pages 1 – 2 — Employee qualification requirements and employer/employee relationship requirements; and employer/employee relationship definitions in CDS.

Individual or Legally Authorized Representative Signature and Date — The individual or his legally authorized representative signs and dates the form indicating the case manager presented this information.

Case Manager/Service Coordinator Signature and Date — The case manager or service coordinator signs and dates the form verifying the information was presented to the individual.