CCMEP Client Exit Checklist

CCMEP Client Exit Checklist
Name

First NameLast Name
Participant Start Date

MonthDayYear
Date
Proposed Exit Date

MonthDayYear
Date
Program

WIOATANFCo-Enrolled
School Status

In School (14-21 be sure to plan for credential attainmentOut of School
Does the participant meet an exit reason per rule 5101:14-1-06?

YesNo
Exit reason per rule 5101:14-1-06

Employment,Military, Education (Participant is successful & no longer needs services)Awarded SSI/SSDI & made application with OODNon-Engagement / five failed attemptsNo longer eligible for fundingGlobally excluded per rule 5101:14-1-07
If box one is checked (Employment,Military, Education) provide details
Enrolled in Secondary/Post-Secondary Education (If yes, enter information below)

YesNo
Training Provider Name & Location
Expected Graduation Date

MonthDayYear
Date
Signed Release to Contact Training Provider

YesNo
Additional Details
Is the participant entering the military? (If yes, enter information below)

YesNo
Branch
Position
Expected Yearly Salary
Contact Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is the participant currently employed? (If yes, enter information below)

YesNo
Employer Name and Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Expected Weekly Earnings
Employer contact information

First NameLast Name
Employer Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Signed Employer Verification Form?

YesNo
Exit Plan Details
Engagement Information
What is the best way to maintain contact during follow-up?

Phone/Cell/TextMail/Email AddressSocial Media
Do you have permission to contact the participant at their place of employment?

YesNo
Do you have permission to contact the employer to obtain employment information?

YesNo
Do you have permission to contact the training provider to obtain training information?

YesNo
Performance Measures

The following measures apply to ISY and OSY in education or training:
Measurable skill gains entered (A gain needs to be attained by June 30th)

YesNo
Type of Gain
How the gain is documented (assessment,report card, etc.)?
Date information entered on skill gain tab?

MonthDayYear
Date
Was a Credential attained?

YesNo
Type of credential
Is employment or post-secondary education required?

YesNo
If yes, education and/or employment/wages data entered?

YesNo
The following three performance measures apply to all participants who are not globally excluded:
Decision
Close all services and exit participant from CCMEP?

YesNo
Comments
Case Manager Name
Case Manager Signature
Should be Empty: