Exhibit_J_-_Service_Closure_Report.docx
DOCX document 19 KB Posted
- Attached to
- Master Agreement AZ|CTR056091
- Contract number
- CTR056091
- Issued by
- Arizona
About this file
This document appears to be a Pre-Employment Transition Services Service Closure Report, a standard form used to document the closure of vocational rehabilitation services for an individual client. The form is designed for use by a vocational rehabilitation (VR) contractor and includes sections for recording basic client information, service outcomes, and reasons for service closure. While specific state agencies or jurisdictions are not explicitly named, the document suggests it is part of a vocational rehabilitation program's standard documentation process.
The form provides a structured mechanism for tracking pre-employment transition service delivery, with detailed sections for capturing service outcomes and potential reasons for service discontinuation. The document allows for documenting both successful and unsuccessful service closures, with checkboxes for various closure scenarios such as client relocation, health issues, incarceration, change in client circumstances, or contractor limitations. The form requires signature validation from the contractor representative, indicating an official process for documenting service transitions and client progress within a vocational rehabilitation service framework.
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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 .