Form Ddd-1406a - Career Preparation And Readiness Quarterly Report
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3ARIZONA DEPARTMENT OF ECONOMIC SECURITY
DDD-1406A FORFF (12-17)
Page 1 of 3
Division of Developmental Disabilities (DDD) ● Employment Support and Services
CAREER PREPARATION AND READINESS
Quarterly Report
QUALIFIED VENDOR NAME:
CONTACT PERSON NAME:
QUALIFIED VENDOR MAILING ADDRESS: (No., Street)
CITY
STATE
ZIP CODE
CPR 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)
3rd Quarter (due by October 15th)
2nd Quarter (due by July 15th)
4th Quarter (due by January 15th)
MEMBER INFORMATION
Ready for referral
Identified for
Original Service
to Vocational
Member Name
Member ID No.
Service End Date
Progressive Move
Start Date
Rehabilitation
(Yes / No)
(Yes / No)
Type of Progressive
Date recommendation for referral to
Date of
Made Progressive Move
Move Made
Name of Employer
Vocational Rehabilitation sent to SC
Progressive Move
(Yes / No)
(Integrated or
Competitive)
Anticipated Date for Member
Month / Year
Month / Year
Month / Year
to Exit the CPR Service
Hours Authorized
Hours Attended
Based on the Individualized Training Agreement, in what employment-related activities has the member participated?
Describe what Job Readiness Assessments have been completed (or an estimated time for completion) including a de-
scription of each activity.
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