Form Ddd-1404a - Employment Support Aide - Quarterly Report
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4ARIZONA DEPARTMENT OF ECONOMIC SECURITY
DDD-1404AFORFF (6-17)
Division of Developmental Disabilities ● Employment Support and Services
EMPLOYMENT SUPPORT AIDE - QUARTERLY REPORT
MEMBER’S NAME:
MEMBER’S DDD ID NUMBER:
MEMBER’S JOB TITLE:
MEMBER’S HIRE DATE:
WEEKLY WORK SCHEDULE:
HOUR WORKED PER WEEK:
QUALIFIED VENDOR NAME:
CONTACT PERSON NAME:
QUALIFIED VENDOR MAILING ADDRESS: (No., Street)
CITY
STATE
ZIP CODE
QUALIFIED VENDOR E-MAIL ADDRESS:
EMPLOYER’S NAME:
EMPLOYER’S PHONE NUMBER:
EMPLOYER’S ADDRESS: (No., Street)
CITY
STATE
ZIP CODE
SUPERVISOR/CONTACT PERSON’S NAME:
SUPPORT COORDINATOR:
DDD EMPLOYMENT SPECIALIST:
REPORT PERIOD
1st Quarter (due by April 15th)
2nd Quarter (due by July 15th)
3rd Quarter (due by October 15th)
4th Quarter (due by January 15th)
Month / Year
Month / Year
Month / Year
Total Hours Worked
SERVICE SETTING
Personal Care Service Authorized
Group Supported Employment
Personal Care Service Provided
Individual Supported Employment
Behavioral Support Service Authorized
Behavioral Support Service Provided
Follow-Along Services
Hours Job-Related Supports Authorized
(only available in follow-along)
Hours Job-Related Supports Provided
(only available in follow-along)
Member Hourly Pay Rate
Routing: Original - Support Coordinator
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Parent category: Legal