| 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 | Address on Agency record marked as Customer |
| TTE 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 on Consumer record with role of “Support Coordinator” |
| Member Name | Consumer Last Name, First Name MI |
| Member ID No | Medicaid Number |
| Identified for Progressive Move (Yes/ No) | Type Yes or No |
| Made Progressive Move (Yes / No | Type Yes or No |
| Type of Progressive Move Made (Integrated or Competitive) | |
| Original Service Start Date | Start Date for a Program Enrollment of TTE |
| Service End Date | End Date for a Program Enrollment of TTE |
| Anticipated Date for Member to Exit the TTE Service | Program Anticipated Completion Date for a Program Enrollment of TTE |
| Hours Authorized | Service Billing Authorization for billing code TTE |
| Hours Attended (By Quarter) | Service hours for service TTE |
| 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) |
| Describe the Types of Activities Involving unpaid work exploration and Job Shadowing experiences that the member has been involved in during the reporting period | |
| Additional Comments | |
| TTE Module | Objective assigned to TTE Curriculum |
| Progress Made…. | |
| Barriers preventing progress and plan of action | |
| Module the individual will participate in (Yes/No) | Set to Yes if the Objective is active in the current or future review periods |
| Date Module Started | Active On date on Objective that has a TTE curriculum assigned |
| 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 |
