Form Ddd-1406b - Career Preparation And Readiness Six-Month Report Page 3

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DDD-1406BFORFF (12-17)

Page 3 of 3

MEMBER INFORMATION

Referred for

Start Date of

Barriers keeping individual from making a

Start Date of

Integrated/

Member CBE

Original CPR

Date CPR

Community

progressive move to community integrated or

Member Name

Member’s DDD ID No.

Competitive

Start Date

Stopped

Integrated

competitive employment

Employment

(Service end date reason)

(Yes / No)

CONTINUATION SHEET:

Routing: Original - Employment Program Specialist

Equal Opportunity Employer/Program • Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the Americans with Disabilities Act of 1990 (ADA), Section 504 of the

Rehabilitation Act of 1973, the Age Discrimination Act of 1975, and Title II of the Genetic Information Nondiscrimination Act (GINA) of 2008; the Department prohibits discrimination

in admissions, programs, services, activities, or employment based on race, color, religion, sex, national origin, age, disability, genetics and retaliation. To request this document in

alternative format or for further information about this policy, contact the Division of Developmental Disabilities ADA Coordinator at 602-542-0419; TTY/TDD Services: 7-1-1. • Free

language assistance for DES services is available upon request. Ayuda gratuita con traducciones relacionadas con los servicios del DES esta disponible a solicitud del cliente.