| Item |
Where the information is found or where it is entered |
| Qualified Vendor Name |
Agency Name on Agency record marked as Customer |
| Contact Person Name |
Use Drop-down to select the person |
| Qualified Vendor Mailing Address |
From Agency record marked as Customer |
| Physical Site Address |
Consumer’s Primary Service Location Address |
| Qualified Vendor e-mail address |
Email address on Agency record marked as customer |
| Support Coordinator |
Support person found in the consumer’s Life Plan Support Network with role of Support Coordinator |
| Member Name |
Consumer Last Name, First Name MI |
| Member ID Number |
Medicaid Number |
| Support Coordinator Phone Number |
Unavailable |
| Report Period |
1st Quarter (due by April 15th), 2nd Quarter (due by July 15th), 3rd Quarter (due by October 15th), 4th Quarter (due by January 15th) |
| Identified for Progressive Move (Yes/ No |
Type Yes or No |
| Made Progressive Move (Yes / No) |
Type Yes or No |
| Hours Authorized |
Hours authorized for the Consumer on an Authorization for the billing code GSE for the Quarter being reviewed |
| Hours Attended |
Total hours recorded in Client Payroll for jobs/activities with a Service Delivery Code of GSE |
| Hours Member Worked |
Total hours recorded in Client Payroll for jobs/activities with a Service Delivery Code of GSE where there are earnings (paid work) |
| Average Hourly Pay |
Earnings for Total Member Worked Hours / Total Member Worked hours. |
| Percent of Time Worked |
Hours Member Worked / Hours Attended. |
| Type of Paid Work the Member is Doing |
????? |
| Member’s Individual Support Plan (ISP) Employment Outcomes |
Objectives with Service of GSE |
| Progress Made on Above Outcomes |
Type response in Summary of Achievements for each objective |
| Barriers Keeping from Making Progressive Move to Community Integrated Employment |
Type response in Barriers Preventing Progressive Progress for each objective |
| Plan of Action to Address Barrier Listed Above |
Type response in Plan of Action for each objective |
| Qualified Vendor Administrator / Designee’s Name |
Last Name, First Name of Person Completing Review |
| Qualified Vendor Administrator / Designee’s Title |
Job Title of person completing review |
