Form Ddd-1401c - Center Based Employment - Quality Assurance Review

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DDD-1401CFORFF (6-17)
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
Division of Developmental Disabilities ● Employment Support and Services
CENTER BASED EMPLOYMENT - QUALITY ASSURANCE REVIEW
QUALIFIED VENDOR NAME:
CONTACT PERSON NAME:
QUALIFIED VENDOR PHONE NUMBER:
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:
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 MEMBERS REACH THOSE OUTCOMES/OBJECTIVES?
HOW DO YOU MEASURE AND RECORD PROGRESS TOWARDS THESE OUTCOMES AND OBJECTIVES?
WHAT TRAINING DID YOU RECEIVE IN DEVELOPING AND TEACHING EMPLOYMENT-RELATED ACTIVITIES? (e.g.
Hygiene, punctuality, time on task, co-worker relations). WHAT ADDITIONAL TRAINING WOULD BE HELPFUL?
WHAT ADDITIONAL EMPLOYMENT SERVICES DOES YOUR AGENCY PROVIDE? Please describe the differences between them.

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