Form Ddd-1402c - Group Supported Employment - Quality Assurance Review
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8ARIZONA DEPARTMENT OF ECONOMIC SECURITY
DDD-1402C FORFF (6-17) Page 1
Division of Developmental Disabilities (DDD)
Group Supported Employment - QUALITY ASSURANCE REVIEW
PERSONAL INFORMATION
(Please print)
QUALIFIED VENDOR’S NAME
CONTACT PERSON NAME
QUALIFIED VENDOR PHONE NUMBER
QUALIFIED VENDOR E-MAIL ADDRESS
QUALIFIED VENDOR MAILING ADDRESS
QUALIFIED VENDOR PHYSICAL ADDRESS
DDD REVIEWER NAME:
DATE OF REVIEW
REVIEWER PHONE NUMBER
DIRECT LINE STAFF INTERVIEW
INTERVIEWEE’S NAME (Print)
INTERVIEWEE’S TITLE
DATE OF HIRE / TIME AT PROGRAM
DATE OF INTERVIEW
How do you know the employment outcomes/objectives of the Members you serve?
How do you help the Member reach those outcomes/objectives?
How do you measure and record progress toward these outcomes and objectives?
Was the training you received adequate or inadequate for you job responsibilities?
What additional training would you like?
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