Exhibit_J_-_Service_Closure_Report.docx
DOCX document 19 KB Posted
- Attached to
- Master Agreement AZ|CTR056087
- Contract number
- CTR056087
- Issued by
- Arizona
About this file
This document is a Service Closure Report form for Pre-Employment Transition Services, designed to document the completion or termination of vocational rehabilitation services for an individual client. The form appears to be a standardized template used by a vocational rehabilitation agency, likely a state-level Department of Rehabilitation Services or similar organization, to track client service outcomes.
The document provides a structured framework for reporting service closure scenarios, with sections for basic client information, successful service closure details, and reasons for unsuccessful service closure. The closure reasons range from client-driven factors such as moving out of the service area or changing circumstances, to contractor-related issues like inability to continue serving the client. The form requires signatures from the contractor representative and includes spaces for specific details about client outcomes, service dates, and authorization numbers.
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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 .