Direct Support Professional Assurance
[To confirm successful completion of testing and competency requirements for the DD Waivers]
I, ______________________ (print) recognize that, as a condition of providing direct support under the BI, FIS and or CL Waivers, the following requirements must be met. I hereby assure that, as a direct support professional delivering one or more of these services, the following events have occurred as described:
1) I have received instruction in the characteristics of developmental disabilities and Virginia’s DD Waivers, person-centeredness, positive behavioral supports, effective communication, DBHDS-identified health risks and the appropriate interventions, and best practices in the support of individuals with developmental disabilities.
2) I have taken and passed (with a total score of 80% or better) the “Orientation Manual Test.”
3) I will complete a DBHDS competency checklist (DMAS P241a) that is maintained in agreement with DBHDS requirements including annual updates and my Supervisor’s signature and if working in a DBHDS-licensed service the appropriate additional competencies checklist(s) when
supporting individuals at Tier Four based on their completed Supports Intensity Scale©.
4) The above events occurred prior to my providing direct reimbursable support services under the BI, FIS, or CL Waivers.
My signature and date below indicate the date I passed the “DSP Orientation Test.”
Direct Support Professional’s Signature Date
Supervisor’s Signature Date
Trainer’s Signature (if applicable) Date
Please keep this assurance and a copy of the scored test on file for viewing during a DMAS Quality Management Review. Keep a copy for your own records.