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Participant Information  \nName:  \nCase \\#:  \nAddress:  \nSupport Coordinator:  \n2. Exploration Provider Information  \nAgency:  \nExploration Facilitator Name (if more than one person, list all names):  \nPrimary Contact (Lead Exploration Facilitator):  \nCell Phone: Email:  \nDate Authorization for Exploration Service Received:  \n3. Background Information (Complete as one of very first Exploration activities; Use to inform remainder of Exploration process)  \nA. Who helps the individual consider options and make decisions about what goals to pursue? (In other words, who else must be  \nsupportive of the individual choosing to pursue integrated work in order for the goal of integrated work to be achieved?  \n\n| Key People to Educate/Engage During Exploration Service | Name(s) and Contact Information |\n| --- | --- |\n| Legally Appointed\u003Cbr>Guardian |  |\n| Designated Representative to Assist with Medicaid-Related\u003Cbr>Decisions |  |\n| Other Family Members Who Are Very Involved with Individual |  |\n| Other Friends Who Are Very Involved with Individual |  |\n\nB. Individual’s Current Situation  \n\n| Current Weekday Activities and Schedule |  |\n| --- | --- |\n| Current Weekend Activities\u003Cbr>and Schedule |  |\n| Prior Experience with Paid Work or Work Experience/Sampling\u003Cbr>(Include dates/duration for each prior experience) |  |\n| Volunteering History/Experience\u003Cbr>(Include dates/duration for each prior experience) |  |\n| Chores Consistently Done\u003Cbr>For Family/Friends/Neighbors/Etc. |  |\n| Strong Interests, Skills, Talents, Hobbies\u003Cbr>(To build on during Exploration service) |  |\n| Benefits Currently Received |  |\n\n4. Exploration Service Log  \nDate Service Started:  \nDate Service Completed:  \nComplete a separate line for each distinct Exploration activity.  \n\n| Date of\u003Cbr>Service | Activity and Location | Time Spent\u003Cbr>Completing\u003Cbr>Activity\u003Cbr>(including\u003Cbr>Travel Time\u003Cbr>with Individual) | Staff Travel\u003Cbr>Time (without\u003Cbr>Individual)\u003Cbr>Associated\u003Cbr>with Activity | Staff Miles\u003Cbr>Driven (during\u003Cbr>travel with and\u003Cbr>without the\u003Cbr>Individual) |\n| --- | --- | --- | --- | --- |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n\nAdd more rows if needed.  \n5. Individual and Allies’Views About the Value of Individualized Integrated Employment  \n\n| Key People Engaged During Exploration Service | Positive Views About Individualized Integrated Employment Upon First Meeting (List All) | Positive Views About Individualized Integrated Employment\u003Cbr>Upon Completion of Exploration Service (List All) |\n| --- | --- | --- |\n| Individual | 1.\u003Cbr>2.\u003Cbr>3. | 1.\u003Cbr>2.\u003Cbr>3. |\n| Legally Appointed\u003Cbr>Guardian | 1.\u003Cbr>2.\u003Cbr>3. | 1.\u003Cbr>2.\u003Cbr>3. |\n| Designated Representative to Assist with Medicaid-Related Decisions | 1.\u003Cbr>2.\u003Cbr>3. | 1.\u003Cbr>2.\u003Cbr>3. |\n| Other Family Members Who Are Very Involved with Person | 1.\u003Cbr>2.\u003Cbr>3. | 1.\u003Cbr>2.\u003Cbr>3. |\n| Other Friends Who Are Very Involved with Person | 1.\u003Cbr>2.\u003Cbr>3. | 1.\u003Cbr>2.\u003Cbr>3. |\n\n6. Addressing Individual and Allies’Need for Accurate/Additional Information to Address Concerns and Hesitations  \n\n| Key People Engaged During Exploration Service | Describe Identified Needs for More Information and/or Correction of Misinformation to Address Concerns/Hesitations Related to Employment | Describe How Each Identified Need Listed in the Previous Column was Addressed Through the Exploration Service |\n| --- | --- | --- |\n| Individual | 1.\u003Cbr>2.\u003Cbr>3. | 1.\u003Cbr>2.\u003Cbr>3. |\n| Legally Appointed\u003Cbr>Guardian | 1.\u003Cbr>2.\u003Cbr>3. | 1.\u003Cbr>2.\u003Cbr>3. |\n| Designated Representative to Assist with Medicaid-Related Decisions | 1.\u003Cbr>2.\u003Cbr>3. | 1.\u003Cbr>2.\u003Cbr>3. |\n| Other Family Members Who Are Very Involved wi","cbCaiplOJN87G4xj","https://ap.wps.com/l/cbCaiplOJN87G4xj","pdf",235705,7,"English","# Participant Information\n## Exploration Provider Information\n## Background Information\n## Exploration Service Log\n## Individual and Allies’Views About the Value of Individualized Integrated Employment\n## Addressing Individual and Allies’Need for Accurate/Additional Information\n## First-Hand and Hands-On Experiences Offered in Exploration Service\n## Summary Data on Exploration Service\n## Outcomes of Exploration Service","[{\"question\":\"该探索服务报告模板需要填写哪些参与者基本信息？\",\"answer\":\"需要填写参与者姓名、案例编号（Case #）、地址以及支持协调员（Support Coordinator）。\"},{\"question\":\"“Exploration Service Log”部分如何记录探索活动？\",\"answer\":\"每一项不同的探索活动需要单独记录服务开始与完成日期、活动及地点、完成活动所用时间（含与参与者的出行时间）、员工在不随行情况下的出行时间以及相关行车里程。\"},{\"question\":\"模板如何评估探索服务的成效与结果？\",\"answer\":\"通过“Summary Data on Exploration Service”的一组是/否问题记录信息与机会是否已提供，并在“Outcomes of Exploration Service”中进一步呈现服务结果。\"}]","Supported Employment - Individual: Exploration Service Report Template | PDF",1789150317]