Form Ddd-1404b - Employment Support Aide - Six-Month Report Page 2

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DDD-1404BFORFF (5-17) Page 2 of 2

MEMBER INFORMATION

CONTINUATION PAGE

Ready for

Receiving

Ready for

Is member in jeopardy of losing their jobs or have they

Receiving

Date ESA

Decrease in

Job Related

Decrease in Job

Decrease in

been terminated from employment.

Behavioral

Personal Care

Member Name

Behavioral

Supports

Related Supports

Personal Care

Services

(Explain why member is at risk of losing their job. If termi-

Intervention

Supports

Discontinued

Intervention

(Follow-along

)

(Follow-along)

Supports

nated list termination date)

(Yes / No)

CONTINUATION SHEET:

Routing: Original - Employment Services Specialist(s) or email to DDDESS@azdes.gov

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.