Exhibit_J_-_Service_Closure_Report.docx
DOCX document 19 KB Posted
- Attached to
- Master Agreement AZ|CTR056118
- Contract number
- CTR056118
- Issued by
- Arizona
About this file
The document is a Service Closure Report form for Pre-Employment Transition Services, designed to document the outcomes of vocational rehabilitation services for an individual client. The form appears to be a standardized template used by a vocational rehabilitation agency (likely state-level) to track service provision, client progress, and reasons for service completion or termination.
The form provides structured sections for capturing client information, service outcomes, and closure reasons. Section II allows for documenting successful service closure by noting client outcomes and skills achieved, while Section III provides a comprehensive list of potential reasons for unsuccessful service closure, including client-related factors such as relocation, health issues, incarceration, or changed circumstances, as well as contractor-related reasons like organizational changes or inability to continue service provision. The document requires signatures from the contractor representative to formalize the service closure process.
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Text version
Pre-Employment Transition Services Service Closure Report
Section I: Basic Information Client's Name:
Contractor Name/Contractor Representative:
| Contract Number: |
| Authorization Number: |
VR Counselor:
Section II: Successful Service Closure Information Date of Service Closure:
Client outcomes achieved and skills demonstrated:
Section III: Unsuccessful Service Closure Information |_| Client was not satisfied with the service provision and requested another Contractor |_| Client moved out of service area |_| Client was unable to complete services due to health issues |_| Client was incarcerated |_| Contractor lost contact with the client |_| Client circumstances have changed and they no longer wish to pursue employment services |_| Contractor can no longer serve client due to organization or business changes |_| Contractor no longer willing to work with client |_| RSA determined services were no longer appropriate |_| Other reason for closure (specify):
Section IV: Signatures:
| Contractor Representative: |
| Date: |
VR 2017-6-13 Page 1 of 1
File details come from the government source that posted it. Updated .