Exhibit_J_-_Service_Closure_Report.docx
DOCX document 19 KB Posted
- Attached to
- Master Agreement AZ|CTR056077
- Contract number
- CTR056077
- Issued by
- Arizona
About this file
The document is a Pre-Employment Transition Services Service Closure Report template, designed for use by a Vocational Rehabilitation (VR) contractor in documenting the closure of client services. While the specific contractor and state are not explicitly named, the form appears to be a standard reporting document used by state vocational rehabilitation agencies to track the outcomes of pre-employment transition services for clients with disabilities.
The report provides a structured format for documenting service closure, with sections detailing client information, successful and unsuccessful service closure reasons. Potential closure scenarios include client satisfaction, relocation, health issues, incarceration, loss of contact, changes in client circumstances, or agency determinations. The document serves as an administrative tool for tracking service provision, client outcomes, and reasons for service termination, though specific pricing, contract terms, or service details are not included in this template.
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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 .