Form Ddd-1402b - Group Supported Employment Services - Six-Month Report
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6ARIZONA DEPARTMENT OF ECONOMIC SECURITY
DDD-1402B FORFF (6-17) Page 1
Division of Developmental Disabilities (DDD)
Group Supported Employment Services - SIX-MONTH REPORT
PERSONAL INFORMATION
(Please print)
QUALIFIED VENDOR’S NAME
CONTACT PERSON NAME
QUALIFIED VENDOR PHONE NUMBER
QUALIFIED VENDOR E-MAIL ADDRESS
REPORT PERIOD (Check one):
January 1 to June 30 (Due by July 31
)
July 1 to December 31 (Due by January 31
)
st
st
QUALIFIED VENDOR MAILING ADDRESS
DDD DISTRICT(S) SERVED
DDD EMPLOYMENT SERVICE SPECIALIST(S)
PLEASE RESPOND TO EACH OF THE OUTCOMES BELOW
OUTCOMES
FREQUENCY
WAY TO MEASURE
WAY TO MEASURE
At least 10% of members
Every six months
Production
PERCENT OF MEMBERS IDENTIFIED FOR
Total members
Total number
based on the Qualified Vendors
Records of
served during
of members
PROGRESSIVE MOVES:
average daily attendance over
members,
six month
identified for
(Divide members identified for progressive moves by total members
a 1 year period will be identified
contracts
period from
progressive
served during six month reporting period)
for progressive moves to
available
January to
moves from
competitive employment.
and time
June:
January to
studies
June:
Total number
Total members
PERCENT OF MEMBERS IDENTIFIED FOR
of members
served during
PROGRESSIVE MOVES:
identified for
twelve month
progressive
(Divide memebers identified for progressive moves by total memebers
period from
moves from
served during six month reporting period)
January to
January to
December:
December:
Provide the average hourly wage of members receiving Group Supported Employment:
Provide the average number of hours per week for members receiving Group Supported Employment:
QUALIFIED VENDOR ADMINSTRATOR/DESIGNEE’S NAME
QUALIFIED VENDOR ADMINISTRATOR/DESIGNEE’S TITLE
QUALIFIED VENDOR ADMINSTRATOR/DESIGNEE’S SIGNATURE
DATE
Routing: Original - Employment Services Specialist(s) or email to DDDESS@azdes.gov
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