| 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 | Person Completing Review chosen for the review |
| Qualified Vendor Mailing Address | (Street, City, State, Zip) Address on Agency record marked as Customer |
| CBE Physical Site Address | Street, City, State, Zip) – 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 No | Consumer Medicaid Number |
| 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 | Service Billing Authorization for billing code CBE |
| Hours Attended | Total hours recorded in Client Payroll for jobs/activities with a Service Delivery Code of CBE |
| Hours Member Worked | Total hours recorded in Client Payroll for jobs/activities with a Service Delivery Code of CBE 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. | Custom Question on Review |
| Member’s Individual Support Plan (ISP) Employment Outcomes | Objectives with CBE service that are active during the current review period date range |
| Progress Made on Above Outcomes | Enter response in Summary of Achievements for each objective |
| Barriers Keeping from Making Progressive Move to Community Integrated Employment | Enter response in Barriers Preventing Progressive Progress for each objective |
| Plan of Action to Address Barrier Listed Above | Enter 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 service | Enter response |
| Qualified Vendor Administrator / Designee’s Name | Last Name, First Name of Person Completing Review from Person |
| Qualified Vendor Administrator / Designee’s Title | Uses the Job Title of person completing review from the Provider Record |
