Arizona Quarterly Report 1406A Center Preparation and Readiness Reference Information

ItemWhere the information is found or where it is entered
Qualified Vendor Name Agency Name
Contact Person Name Use Dropdown to select name
Qualified Vendor Mailing Address Agency Address
CPR Physical Site Address Consumer’s Primary Service Location Address
Qualified Vendor e-mail address Agency Email address
Support Coordinator Life Plan Support Network person 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 / No) Type Yes or No
Date of Progressive Move Enter Date
Type of Progressive Move Made (Integrated or Competitive) Type Integrated or Competitive
Name of Employer Type Name of Employer
Original Service Start Date Program Enrollment date for Program with a Program Code of DPR
Service End Date Program Unenrollment date for Program with a Program Code of DPR
Ready for referral to Vocational Rehabilitation (Yes/No) Type Yes or No
Date recommendation for referral to Vocational Rehabilitation sent to SC –Type the Date
Hours Authorized Service Billing authorization for the billing code DPR
Hours Attended (By Quarter) Service hours for Service DPR
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)
Anticipated Date for Member to Exit the CPR Service Program Anticipated Completion Date for Program Enrollment with a Program Code of DPR
Based on the individualized training agreement…Type response
Describe what Job Readiness Assessments have been completedType response
Describe what Work Incentive Counseling…Type response
Describe what Member representation… Type response
Describe what Career Exploration…Type response
Describe what community trial work… Type response
Describe other types of employment related activities… Type response
Other…Type response
Barriers preventing progressive movement into competitive … Type response
Qualified Vendor Administrator / Designee’s Name Person completing the review ‘s name is auto generated
Qualified Vendor Administrator / Designee’s Title Person completing review ‘s title is auto generated

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