Form Ddd-1404b - Employment Support Aide - Six-Month Report
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2ARIZONA DEPARTMENT OF ECONOMIC SECURITY
DDD-1404BFORFF (5-17)
Division of Developmental Disabilities ● Employment Support and Services
EMPLOYMENT SUPPORT AIDE - SIX-MONTH REPORT
QUALIFIED VENDOR NAME:
CONTACT PERSON NAME:
QUALIFIED VENDOR PHONE NUMBER:
REPORT PERIOD:
January 1 to June 30 (due by July 31st)
July 1 to December 31 (due by January 31st)
QUALIFIED VENDOR MAILING ADDRESS: (No., Street)
CITY
STATE
ZIP CODE
QUALIFIED VENDOR E-MAIL ADDRESS:
DDD DISTRICT(S) SERVED:
DDD EMPLOYMENT SERVICE SPECIALIST(S):
MEMBER INFORMATION
Ready for
Receiving
Ready for
Ready for
Is member in jeopardy of losing their jobs or have they
Receiving
Receiving
Date ESA
Decrease in
Job Related
Decrease in Job
Decrease in
been terminated from employment.
Behavioral
Personal Care
Member Name
Services
Behavioral
Supports
Related Supports
Personal Care
Intervention
Supports
(Explain why member is at risk of losing their job. If termi-
Intervention
(Follow-along)
(Follow-along)
Supports
Discontinued
nated list termination date)
(Yes / No)
(Yes / No)
(Yes / No)
(Yes / No)
(Yes / No)
(Yes / No)
CONTINUATION SHEET:
QUALIFIED VENDOR ADMINISTRATOR / DESIGNEE’S NAME (Print)
QUALIFIED VENDOR ADMINISTRATOR / DESIGNEE’S TITLE
QUALIFIED VENDOR ADMINISTRATOR / DESIGNEE’S SIGNATURE
DATE
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