| 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 Dropdown to select the name of the person |
| Qualified Vendor Mailing Address |
Address on Agency record marked as Customer |
| 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 |
Medicaid Number |
| DDD Employment Specialist |
Support person found in the consumer’s Life Plan Support Network with role of Employment Specialist |
| Employer Name |
Employer Name on Placement active during the Review Period Date Range |
| Employer Address (Street, City, State, Zip) |
Employment | Placement | Employer Address |
| Supervisor/Contact Person Name |
Supervisor on Placement |
| Member Job Title |
Job Title on Placement |
| Member Hire Date |
Hire Date on Placement |
| Weekly Work Schedule |
Work Schedule on Placement |
| Hours Worked per Week |
Hours Per Week on Placement |
| 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) |
| Hours Member Worked |
Hours on Hours and Earnings record |
| Personal Care Services Authorized |
Service Billing Authorization for PC |
| Personal Care Service Provided |
Service hours for the Consumer for Service PC |
| Behavioral Support Service Authorized |
Service Billing Authorization for BSS |
| Behavioral Support Service Provided |
Service hours for the Consumer for Service BSS |
| Hours Job Related Support Authorized |
Service Billing Authorization for HJRS |
| Hours Job Related Support Provided |
Service hours for the Consumer for Service HJRS for the Quarter being reviewed |
| Member Hourly Pay Rate |
Hourly Rate on Placement |
| Behavioral Intervention section:
Outcome as Stated in the ISP – |
Outcome with Behavior Intervention service |
| Progress Made, Barriers, Plan of Action |
Objective questions for Objectives with Behavior Intervention service. Combine questions into a single note with a line between each note (Progress Made, Barriers, Plan of Action) |
| Follow-Along Services section:
Outcome as Stated in the ISP |
Outcome with Follow-along service |
| Progress Made, Barriers, Plan of Action |
Objective questions for Objectives with Follow-along service. Combine questions into a single note with a line between each note (Progress Made, Barriers, Plan of Action) |
| Employment Support Aide Services Log:
Date
Service Hours
Summary of Services Rendered
Employment Support Aide’s Signature |
This list will display Service Records with an Activity of “Job Coaching” for the Consumer on the report.
Service Record date
Elapsed hours on the Service Record
Contents of the Service Note on the Service Record
Blank |
| 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 |
