Form Ddd-1401a - Quarterly Report Center-Based Employment Services Page 2

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DDD-1401AFORFF (5-17) Page 2 of 2

PROGRESS MADE ON ABOVE OUTCOME(S):

BARRIERS KEEPING INDIVIDUAL FROM MAKING A PROGRESSIVE MOVE TO COMMUNITY INTEGRATED EMPLOYMENT. (i.e. Member choice; family

choice; challenging behavior; health issues; no transportation; limited job availability; other)

PLAN OF ACTION TO ADDRESS BARRIER LISTED ABOVE: MEMBER EDUCATION; FAMILY EDUCATION; DB101, BEHAVIOR TREATMENT PLANNING;

EMPLOYER OUTREACH; HEALTH CARE CHANGES; OTHER

IF MEMBER DID NOT PARTICIPATE IN PAID WORK 75% OF THEIR TIME IN ATTENDANCE, DESCRIBE IN DETAIL THE WORK-RELATED ACTIVITIES THE

MEMBER WAS INVOLVED IN DURING BILLED HOURS OF SERVICE:

QUALIFIED VENDOR ADMINISTRATOR / DESIGNEE’S NAME (Print)

QUALIFIED VENDOR ADMINISTRATOR / DESIGNEE’S TITLE

QUALIFIED VENDOR ADMINISTRATOR / DESIGNEE’S SIGNATURE

DATE

Routing: Original - Support Coordinator

Equal Opportunity Employer/Program • Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the Americans with Disabilities Act of 1990 (ADA), Section 504 of the

Rehabilitation Act of 1973, the Age Discrimination Act of 1975, and Title II of the Genetic Information Nondiscrimination Act (GINA) of 2008; the Department prohibits discrimination

in admissions, programs, services, activities, or employment based on race, color, religion, sex, national origin, age, disability, genetics and retaliation. To request this document in

alternative format or for further information about this policy, contact the Division of Developmental Disabilities ADA Coordinator at 602-542-0419; TTY/TDD Services: 7-1-1. • Free

language assistance for DES services is available upon request. Ayuda gratuita con traducciones relacionadas con los servicios del DES esta disponible a solicitud del cliente.