| 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 |
