Arizona Quarterly Report 1401A Center Based Employment Reference Information

ItemWhere the information is found or where it is entered
Qualified Vendor NameAgency Name on Agency record marked as Customer
Contact Person NamePerson Completing Review chosen for the review
Qualified Vendor Mailing Address(Street, City, State, Zip) Address on Agency record marked as Customer
CBE Physical Site AddressStreet, City, State, Zip) – Consumer’s Primary Service Location Address)
Qualified Vendor e-mail addressEmail address on Agency record marked as customer
Support CoordinatorSupport person found in the consumer’s Life Plan Support Network with role of Support Coordinator
Member NameConsumer Last Name, First Name MI
Member ID NoConsumer Medicaid Number
Report Period1st 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 AuthorizedService Billing Authorization for billing code CBE
Hours AttendedTotal hours recorded in Client Payroll for jobs/activities with a Service Delivery Code of CBE
Hours Member WorkedTotal hours recorded in Client Payroll for jobs/activities with a Service Delivery Code of CBE where there are earnings (paid work)
Average Hourly PayEarnings for Total Member Worked Hours / Total Member Worked hours.
Percent of Time WorkedHours Member Worked / Hours Attended.
Type of Paid Work the Member is Doing.Custom Question on Review
Member’s Individual Support Plan (ISP) Employment OutcomesObjectives with CBE service that are active during the current review period date range
Progress Made on Above OutcomesEnter response in Summary of Achievements for each objective
Barriers Keeping from Making Progressive Move to Community Integrated EmploymentEnter response in Barriers Preventing Progressive Progress for each objective
Plan of Action to Address Barrier Listed AboveEnter response in Plan of Action for each objective
If Member did not participate in Paid Work 75% of their time in attendance, describe in detail the work-related activities the member was involved in during billed hours of serviceEnter response
Qualified Vendor Administrator / Designee’s NameLast Name, First Name of Person Completing Review from Person
Qualified Vendor Administrator / Designee’s TitleUses the Job Title of person completing review from the Provider Record

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Arizona Quarterly Report 1402A Group Supported Employment Reference Information

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