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Arizona Quarterly Report 1405A Transition to Employment Review Reference Information

Arizona Quarterly Report 1405A Transition to Employment Review Reference Information

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
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