Form Ddd-1404a - Employment Support Aide - Quarterly Report Page 3

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DDD-1404AFORFF (6-17) Page 3 of 4

EMPLOYMENT SUPPORT AIDE SERVICES LOG

Provide a detailed summary of services rendered, including a description of personal care activities, behavioral supports and job-related supports. Each contact entry

must be signed by the Employment Support Aide. Attach additional sheets as necessary.

DATE

SERVICE HOURS

SUMMARY OF SERVICES RENDERED

EMPLOYMENT SUPPORT AIDE’S SIGNATURE

QUALIFIED VENDOR ADMINISTRATOR / DESIGNEE’S NAME (Print)

QUALIFIED VENDOR ADMINISTRATOR / DESIGNEE’S TITLE

QUALIFIED VENDOR ADMINISTRATOR / DESIGNEE’S SIGNATURE

DATE