Exhibit_J_-_Service_Closure_Report.docx
DOCX document 19 KB Posted
- Attached to
- Master Agreement AZ|CTR056097
- Contract number
- CTR056097
- Issued by
- Arizona
About this file
This document is a Service Closure Report template for Pre-Employment Transition Services, likely used by a vocational rehabilitation (VR) agency to document the status of client service provisions. The form appears designed for tracking client outcomes in employment transition services, with sections for recording basic client information, successful and unsuccessful service closure reasons, and signature documentation.
The template provides a comprehensive framework for contractors to report on client service status, with multiple checkboxes indicating potential reasons for service closure, such as client relocation, health issues, incarceration, changed circumstances, or agency determination that services are no longer appropriate. While specific pricing, contract amounts, or renewal terms are not detailed in this document, the form suggests a structured approach to managing pre-employment transition services with specific documentation requirements for service completion or termination.
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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 .