| Item |
Where the information is found or where it is entered |
| Qualified Vendor Name |
Agency Name |
| Contact Person Name |
Use Dropdown to select name |
| Qualified Vendor Mailing Address |
Agency Address |
| CPR Physical Site Address |
Consumer’s Primary Service Location Address |
| Qualified Vendor e-mail address |
Agency Email address |
| Support Coordinator |
Life Plan Support Network person 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 |
| Date of Progressive Move |
Enter Date |
| Type of Progressive Move Made (Integrated or Competitive) |
Type Integrated or Competitive |
| Name of Employer |
Type Name of Employer |
| Original Service Start Date |
Program Enrollment date for Program with a Program Code of DPR |
| Service End Date |
Program Unenrollment date for Program with a Program Code of DPR |
| Ready for referral to Vocational Rehabilitation (Yes/No) |
Type Yes or No |
| Date recommendation for referral to Vocational Rehabilitation sent to SC – |
Type the Date |
| Hours Authorized |
Service Billing authorization for the billing code DPR |
| Hours Attended (By Quarter) |
Service hours for Service DPR |
| 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) |
| Anticipated Date for Member to Exit the CPR Service |
Program Anticipated Completion Date for Program Enrollment with a Program Code of DPR |
| Based on the individualized training agreement… |
Type response |
| Describe what Job Readiness Assessments have been completed |
Type response |
| Describe what Work Incentive Counseling… |
Type response |
| Describe what Member representation… |
Type response |
| Describe what Career Exploration… |
Type response |
| Describe what community trial work… |
Type response |
| Describe other types of employment related activities… |
Type response |
| Other… |
Type response |
| Barriers preventing progressive movement into competitive … |
Type response |
| Qualified Vendor Administrator / Designee’s Name |
Person completing the review ‘s name is auto generated |
| Qualified Vendor Administrator / Designee’s Title |
Person completing review ‘s title is auto generated |
