Form Ddd-1405a - Transition To Employment Services Quarterly Report
Download a blank fillable Form Ddd-1405a - Transition To Employment Services Quarterly Report in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Ddd-1405a - Transition To Employment Services Quarterly Report with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3ARIZONA DEPARTMENT OF ECONOMIC SECURITY
DDD-1405AFORFF (12-17)
Division of Developmental Disabilities ● Employment Support and Services
TRANSITION TO EMPLOYMENT SERVICES
Quarterly Report
QUALIFIED VENDOR NAME:
CONTACT PERSON NAME:
QUALIFIED VENDOR MAILING ADDRESS: (No., Street)
CITY
STATE
ZIP CODE
TTE PHYSICAL SITE ADDRESS: (No., Street)
CITY
STATE
ZIP CODE
QUALIFIED VENDOR E-MAIL ADDRESS:
MEMBER NAME:
SUPPORT COORDINATOR:
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)
Original Service
Identified for Progressive
Made Progressive Move
Type of Progressive Move Made
Member Name
Member ID No.
Service End Date
Start Date
Move (Yes / No)
(Yes / No)
(Integrated or Competitive)
Anticipated Date for Member to Exit the TTE Service:
Month / Year
Month / Year
Month / Year
Hours Authorized
Hours Attended
DESCRIBE THE TYPES OF ACTIVITIES INVOLVING UNPAID WORK EXPLORATION AND JOB SHADOWING EXPERIENCES THAT THE MEMBER HAS
BEEN INVOLVED IN DURING THE REPORTING PERIOD:
ADDITIONAL COMMENTS:
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal