| 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 | 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 Number | Medicaid Number |
| Support Coordinator Phone Number | Unavailable |
| 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 | 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 Above | Type 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 |
