Form Ddd-1406b - Career Preparation And Readiness Six-Month Report
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3ARIZONA DEPARTMENT OF ECONOMIC SECURITY
DDD-1406BFORFF (12-17)
Page 1 of 3
Division of Developmental Disabilities ● Employment Support and Services
CAREER PREPARATION AND READINESS
SIX-MONTH REPORT
●
QUALIFIED VENDOR NAME:
CONTACT PERSON NAME:
QUALIFIED VENDOR PHONE NUMBER:
REPORT PERIOD:
January 1 to June 30 (due by July 31st)
July 1 to December 31 (due by January 31st)
CPR PHYSICAL SITE ADDRESS: (No., Street)
CITY
STATE
ZIP CODE
QUALIFIED VENDOR MAILING ADDRESS: (No., Street)
CITY
STATE
ZIP CODE
QUALIFIED VENDOR E-MAIL ADDRESS:
DDD DISTRICT(S) SERVED:
DDD EMPLOYMENT SERVICE SPECIALIST(S):
MEMBER INFORMATION
Referred for
Start Date of
Barriers keeping individual from making a
Integrated/
Start Date of
Member CBE
Original CPR
Date CPR
Community
progressive move to community integrated or
Member Name
Member’s DDD ID No.
Competitive
Competitive
Start Date
Start Date
Stopped
Integrated
competitive employment
Employment
Employment
Employment
(Service end date reason)
(Yes / No)
CONTINUATION SHEET:
Routing: Original - Employment Services Specialist(s) or email to DDDESS@azdes.gov
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