Form Ddd-1401a - Quarterly Report Center-Based Employment Services
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2ARIZONA DEPARTMENT OF ECONOMIC SECURITY
DDD-1401AFORFF (5-17)
Division of Developmental Disabilities ● Employment Support and Services
QUARTERLY REPORT
CENTER-BASED EMPLOYMENT SERVICES
QUALIFIED VENDOR NAME:
CONTACT PERSON NAME:
QUALIFIED VENDOR MAILING ADDRESS: (No., Street)
CITY
STATE
ZIP CODE
CBE PHYSICAL SITE ADDRESS: (No., Street)
CITY
STATE
ZIP CODE
QUALIFIED VENDOR E-MAIL ADDRESS:
MEMBER NAME:
SUPPORT COORDINATOR:
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)
Identified for Progressive Move
Member Name
Member ID No.
Made Progressive Move (Yes / No)
(Yes / No)
Type of Paid Work the Member is Doing:
Month / Year
Month / Year
Month / Year
Hours Authorized
Hours Attended
Hours Worked
Average Hourly Pay
Percent of Time Worked:
NaN
NaN
NaN
(Divide hours worked by hours of attendance)
MEMBER’S INDIVIDUAL SUPPORT PLAN (ISP) EMPLOYMENT OUTCOME(S):
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