Arizona Quarterly Report 1402A Group Supported Employment Reference Information

ItemWhere 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 NumberMedicaid Number
Support Coordinator Phone NumberUnavailable
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/ NoType 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 AboveType 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

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Arizona Quarterly Report 1402A Group Supported Employment Reference Information

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