| 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 |
