Form Ddd-1403a - Individual Supported Employment Services Quarterly Report
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2ARIZONA DEPARTMENT OF ECONOMIC SECURITY
DDD-1403A FORPDF (11-17)
Page 1 of 2
Division of Developmental Disabilities (DDD)
Employment Supports & Services
INDIVIDUAL SUPPORTED EMPLOYMENT SERVICES
Quarterly Report
QUALIFIED VENDOR INFORMATION
QUALIFIED VENDOR NAME
CONT ACT PERSON NAME
MAILING ADDRESS (No., Street)
CITY
STATE
ZIP CODE
EMAIL ADDRESS
MEMBER’S NAME
SUPPORT COORDINATOR
REPORT PERIOD (Check one):
1st Quarter (Due by April 15th)
3rd Quarter (Due by October 15th)
2nd Quarter (Due by July 15th)
4th Quarter (Due by January 15th)
JOB SEARCH
JOB SEARCH
EMPLOYMENT
JOB COACH
JOB COACH
EMPLOYMENT
MEMBER NAME
MEMBER ID NUMBER
SERVICE
SERVICE
OBTAINED
SERVICE
SERVICE
MAINTAINED
START DATE
END DATE
(Yes/No)
START DATE
END DATE
(Yes/No)
MONTH/YEAR
MONTH/YEAR
MONTH/YEAR
HOURS AUTHORIZED:
HOURS BILLED:
HOURS MEMBER WORKED:
MEMBER’S EMPLOYER
MEMBER’S JOB TITLE
HOURLY PAY
HOURS WORKED PER WEEK
Member’s Individual Support Plan (ISP) Employment Outcome(s):
See page 2 for EOE/ADA/LEP/GINA disclosures
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