| 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 |
