Form Ddd-1402a Forff - Group Supported Employment Services Quarterly Report
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2ARIZONA DEPARTMENT OF ECONOMIC SECURITY
DDD-1402A FORFF (6-17) Page 1
Division of Developmental Disabilities (DDD)
Group Supported Employment Services - QUARTERLY REPORT
PERSONAL INFORMATION
(Please print)
MEMBER NAME
MEMBER I.D. NUMBER
SUPPORT COORDINATOR
SUPPORT COORDINATOR PHONE NUMBER
QUALIFIED VENDOR’S NAME
CONTACT PERSON NAME
QUALIFIED VENDOR ADDRESS (P.O. Box, No., Street, City, State, ZIP)
PHYSICAL SITE ADDRESS
QUALIFIED VENDOR E-MAIL ADDRESS
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)
Yes
No
Yes
No
IDENTIFIED FOR PROGRESSIVE MOVE
MADE PROGRESS MOVE
MONTH/YEAR
MONTH/YEAR
MONTH/YEAR
HOURS AUTHORIZED
HOURS ATTENDED
HOURS WORKED
AVERAGE HOURLY PAY
PERCENT OF TIME WORKED
(Divide hours worked by hours of
attendance)
Type of paid work the Member is doing
Member’s Individual Support Plan (ISP) Employment Outcome(s):
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