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 |