Arizona Quarterly Report 1405A Transition to Employment Review 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 AddressAddress on Agency record marked as Customer
TTE Physical Site AddressConsumer’s Primary Service Location Address
Qualified Vendor e-mail addressEmail address on Agency record marked as customer
Support CoordinatorSupport person on Consumer record with role of “Support Coordinator”
Member NameConsumer Last Name, First Name MI
Member ID NoMedicaid Number
Identified for Progressive Move (Yes/ No)Type Yes or No
Made Progressive Move (Yes / NoType Yes or No
Type of Progressive Move Made (Integrated or Competitive)
Original Service Start DateStart Date for a Program Enrollment of TTE
Service End DateEnd Date for a Program Enrollment of TTE
Anticipated Date for Member to Exit the TTE ServiceProgram Anticipated Completion Date for a Program Enrollment of TTE
Hours AuthorizedService Billing Authorization for billing code TTE
Hours Attended (By Quarter)Service hours for service TTE
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)
Describe the Types of Activities Involving unpaid work exploration and Job Shadowing experiences that the member has been involved in during the reporting period
Additional Comments
TTE ModuleObjective assigned to TTE Curriculum
Progress Made….
Barriers preventing progress and plan of action
Module the individual will participate in (Yes/No)Set to Yes if the Objective is active in the current or future review periods
Date Module StartedActive On date on Objective that has a TTE curriculum assigned
Qualified Vendor Administrator / Designee’s NameLast Name, First Name of Person Completing Review
Qualified Vendor Administrator / Designee’s TitleJob Title of person completing review

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Arizona Quarterly Report 1402A Group Supported Employment Reference Information

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