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

Agency Name

Agency Address

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.
(DMAS P242a)