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 |