Form 6519, Deaf Blind with Multiple Disabilities (DBMD) Record of Completion for General Orientation Training

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Effective Date

5/2025
6519.pdf

Instructions

Updated: 5/2025

Note: The term person when used in this form refers to an individual per 26 Texas Administrative Code (TAC) Section 260.5.

Purpose

To provide a standardized record of completion for DBMD General Orientation training.

Procedure

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 and Choking Prevention.

Training must occur per the timeframes outlined in 26 Texas Administrative Code (TAC) 260.205 Training.

Form Retention and Submission

Keep this form per record retention requirements outlined in the TAC. The DBMD program provider is not required to submit the forms to HHSC on completion but must maintain the forms in personnel records and provide a copy to HHSC on request.

Detailed Instructions

Service Provider’s Name — Enter or print the name of the service provider who completed the training.

Trainer’s Name — Enter or print the name of the DBMD program provider staff member who provided the training.

Date Training Completed — Enter the month, day and year the service provider completed the training.

Service Provider Type, check one or more — Indicate which service provider type is completing 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
  • Employment Readiness
  • Individualized Skills and Socialization
  • Intervener, I, II, III
  • Licensed Assisted Living, 18 and 24 Hour
  • Licensed Home Health Assisted Living
  • Nursing – RN or LVN, Specialized RN or LVN
  • Respite – In-Home and Out-of-Home
  • Supported Employment
  • Transportation – Residential Habilitation

Reason for Training — Mark 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.

Section 1: General Orientation Training – Complete all items in this section.

Rights of a Person — Mark to indicate instruction has been provided to the service provider that details the rights of a person. Program providers may use the Your Rights Booklet (PDF) as a reference material.

Confidentiality — Mark to indicate instruction has been provided to the service provider that details confidentiality requirements.

Program Provider’s Complaint Process — Mark to indicate instruction has been provided to the service provider that details the program provider’s complaint process.

DBMD Program and CFC Requirements — Mark to indicate instruction has been provided to the service provider that includes DBMD Program and CFC, including requirements of Chapter 260 and the DBMD Program and CFC services specified in 26 TAC 260.7 Description of the DBMD Program and CFC.

Section 2: Abuse, Neglect and Exploitation (ANE) — Complete all items in this section.

Note: A program provider must make sure a program director, service provider, staff person and volunteer receive training on abuse, neglect and exploitation before assuming job duties and annually thereafter.

Abuse, Neglect and Exploitation training, including: — Mark to indicate 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 a person.

Per Appendix XI, Abuse, Neglect and Exploitation Training and Competency Test of the DBMD Program Manual, the program provider must make sure a person trained on abuse, neglect and exploitation completes the ANE Competency Test before the service provider assumes job duties and annually thereafter — Mark to indicate the program director, service provider, staff or volunteer completed the mandatory computer-based HHSC ANE Competency Test.

The service provider must receive a score of at least 80%. 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 on request.

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 a person has been, or is being, abused, neglected or exploited (applicable to family members or someone with an ongoing relationship with the person who is not providing care for them under an HCSSA in any capacity) by:

Note: As of Sept. 1, 2023, an HCSSA is required to report a allegation of abuse, neglect or exploitation by a service provider to HHSC Complaint and Incident Intake. The methods for reporting include:

Section 3: Cardiopulmonary Resuscitation and Choking Prevention Training — Mark to indicate the service provider’s CPR and Choking Prevention certification dates have been reviewed. Certification must be maintained as current and be available for review on request.

Note: The training received to obtain the certification must include an in-person evaluation by a qualified service provider.

CPR and Choking Prevention Certification Date — Enter the month, day, and year of the service provider’s current certification in:

  • cardiopulmonary resuscitation; and
  • choking prevention.

CPR and Choking Prevention Certification Expiration Date: — Enter the date (month, day, year) in which the service provider’s current certification will expire.

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 completed 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 — The person who verified CPR, Choking Prevention certification and completion of computer-based training requirements signs and dates the form. This person may be someone other than the person providing general orientation training.

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.