To provide a standardized record of completion for Deaf Blind with Multiple Disabilities (DBMD) General Orientation training.
When to Prepare
The DBMD program provider completes Form 6519 to document the completion of:
- general orientation training;
- mandatory HHSC ANE computer-based competency tests; and
- certification in CPR, First Aid and Choking Prevention.
Training must occur in accordance with the timeframes outlined in 40 TAC 42.403 Training or its successor 26 TAC 260.205 Training.
Form Retention and Submission
Keep this form per record retention requirements outlined in the Texas Administrative Code. The DBMD Program Provider is not required to submit the forms to HHSC upon completion but must maintain the forms in personnel records and provide a copy to HHSC upon request.
Name of the Service Provider— Enter or print the name of the service provider who completed the training.
Name of Trainer— Enter or print the name of the DBMD program provider staff member who conducted the training.
A program provider that develops and conducts its own trainings must ensure that the staff person who develops and conducts the training has successfully completed HHSC training on the specified topic. Documentation of the completion must be maintained in the personnel file of the staff person developing and conducting the specified training.
Date Training Completed— Enter the date (month, day, year) that the service provider completed the training.
Service Provider Type (Check one or more)— Check the box(es) to indicate which service provider type is receiving the training. General orientation training is required for program directors and all program provider staff, including subcontractors, who provide:
- Case Management
- Community First Choice Personal Assistance Services Habilitation (PAS/Hab)
- Employment Assistance
- Individualized Skills and Socialization
- Intervener, I, II, III
- Licensed Assisted Living (18 and 24 Hour)
- Licensed Home Health Assisted Living
- Respite (In-Home and Out-of-Home)
- Supported Employment
- Transportation – Residential Habilitation
General orientation training is not required for registered nurses (RN) or licensed vocational nurses (LVN).
Reason for Training— Mark the appropriate box to indicate the reason for the training (choose one option):
- Initial Training – Select this option when the service provider is a new employee.
- Annual Renewal – Select this option when the service provider is completing their required annual training.
CPR, First Aid and Choking Prevention Certification Date:– Enter the date (month, day, year) of the service provider’s current certification in:
- cardiopulmonary resuscitation;
- basic first aid; and
- choking prevention.
CPR, First Aid and Choking Prevention Certification Expiration Date: – Enter the date (month, day, year) in which the service provider’s current certification will expire.
Section 1: General Orientation Training – Complete all items in this section.
Rights of an Individual — Mark the box to indicate that instruction has been provided to the service provider detailing the rights of an individual. Program providers may use the Your Rights Booklet as a reference material.
Confidentiality — Mark the box to indicate that instruction has been provided to the service provider detailing confidentiality requirements.
Program Director’s Complaint Process — Mark the box to indicate that instruction has been provided to the service provider detailing the program provider’s complaint process.
DBMD Program and CFC Requirements — Mark the box to indicate that instruction has been provided to the service provider that includes DBMD Program and CFC, including requirements of Chapter 42 and the DBMD Program and CFC services specified in 40 TAC 42.104 Description of Deaf Blind with Multiple Disabilities (DBMD) Waiver Program and CFC or its successor 26 TAC 260.7 Description of Deaf Blind with Multiple Disabilities Waiver Program and CFC.
Section 1: Abuse, Neglect & Exploitation – Complete all items in this section.
Abuse, Neglect & Exploitation training, including: — Mark the box to indicate that instruction has been provided and the service provider is knowledgeable of:
- acts that constitute abuse, neglect and exploitation;
- signs and symptoms of abuse, neglect, and exploitation;
- methods to prevent abuse, neglect, and exploitation; and
- instruction on reporting an allegation of abuse, neglect, or exploitation of an individual.
Instructions for reporting an allegation of abuse, neglect, or exploitation of an individual was provided to the above-named service provider in writing — Mark the box to indicate that written instructions detailing the process for reporting an allegation of abuse, neglect, or exploitation has been provided to the service provider.
Service providers must be instructed to report to Department of Family and Protective Services (DFPS) immediately, but not later than 24 hours, after having knowledge or suspicion that an individual has been, or is being, abused, neglected or exploited by:
- calling the DFPS Abuse Hotline toll-free phone number, 800-252-5400; or
- using the DFPS Abuse Hotline website
Per the Appendix XI, Abuse, Neglect, and Exploitation Training and Competency Test of the DBMD Program Manual, the program provider must ensure that a person trained on abuse, neglect and exploitation completes the ANE Competency Test before the service provider assumes job duties and annually thereafter – Mark the box to indicate that the service provider completed the mandatory computer-based HHSC ANE Competency Test.
The service provider must receive a score of at least 80 percent. The HHSC training certificate issued after the service provider achieves the required score must be maintained in the employee’s personnel record and must be available for review upon request.
Section 3: Cardiopulmonary Resuscitation, First Aid, and Choking Prevention Training— Mark the box to indicate that the service provider’s CPR, First Aid and Choking Prevention certification dates have been reviewed. Certification must be maintained as current and be available for review upon request.
Note: The training received to obtain the certification must include an in-person evaluation by a qualified service provider.
Signature of Service Provider and Date— The service provider signs and dates the form. The service provider’s signature is a confirmation that they have received training on the training topics documented on the form.
Signature of Trainer and Date— The trainer signs and dates the form. The trainer’s signature is a confirmation that instruction has been provided to the service provider on the training topics documented on the form.
Signature of Person Providing Verification and Date— If CPR, First Aid, Choking Prevention certification and computer-based training requirements were verified by someone other than the person providing general orientation, that person signs and dates the form. The person’s signature is a confirmation that completion of those requirements was verified.
Contact Program Staff
Email the CLASS/DBMD Provider Monitoring team for questions about the form or instructions.
Email the Long Term Services and Support (LTSS) Policy team for questions about DBMD program policies.