Form Ddd-1405bforff - Six Month Report Transition To Employment Services
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5ARIZONA DEPARTMENT OF ECONOMIC SECURITY
DDD-1405BFORFF (4-17)
Division of Developmental Disabilities ● Employment Support and Services (DDD)
Employment Supports and Services
SIX MONTH REPORT
TRANSITION TO EMPLOYMENT SERVICES
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)
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:
DDD DISTRICT(S) SERVED:
DDD EMPLOYMENT SERVICE SPECIALIST(S):
MEMBER INFORMATION
Referred for
Barriers keeping individual from making
Referred for
Made
community
Original TTE
Date TTE
Type of Progressive
a progressive move to community
competitive
Progressive
Member Name
Member’s DDD ID No.
integrated
Start Date
stopped
Move Made
integrated or competitive employment
employment
Move
employment
(Service end date reason)
(Yes / No)
(Yes / No)
(Yes / No)
CONTINUATION SHEET:
Routing: Original - Employment Services Specialist(s) or email to DDDESS@azdes.gov
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