Exhibit_J_-_Service_Closure_Report.docx
DOCX document 19 KB Posted
- Attached to
- Master Agreement AZ|CTR056121
- Contract number
- CTR056121
- Issued by
- Arizona
About this file
This document is a Service Closure Report template 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 associated with a state vocational rehabilitation (VR) agency and is structured to capture detailed information about service outcomes, whether successful or unsuccessful.
The document provides a standardized mechanism for contractors to report on client service status, with sections detailing successful service closure outcomes, potential reasons for unsuccessful closure, and spaces for signatures. The form includes checkboxes for various closure scenarios such as client satisfaction, relocation, health issues, incarceration, loss of contact, changed circumstances, or agency determination. While specific contract details are not fully evident, the form suggests this is part of a broader pre-employment transition services contract focused on supporting individuals through vocational rehabilitation and employment services.
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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 .