SR 00-50 Dated 11/00

STATE OF NEW HAMPSHIRE

INTER-DEPARTMENT COMMUNICATION

SUMMARY

This SR releases revised Form 125, Transfer of Client Records, and Form 125(i), Instructions to Form 125. These forms have been revised to facilitate processing of transfer of records from one District Office to another and/or to State Office. Form 125, previously a 3 part NCR document, is now an electronic form fill-in document.

This SR also releases new Form NHEP125, Transfer of NHEP Case Records, and Form NHEP125(i), Instructions to Form NHEP125. These forms are being released to facilitate processing of transfer of records from one NHEP Team to another.

Form NHEP240, Agency Partner Participation Form, is also being revised and re-released by this SR. Form NHEP240 has been revised to reflect minor changes to the check-off boxes as explained in the text of this SR. Form NHEP240 will continue to be used in its unrevised format until revised versions are printed and distributed.

POLICY

Form 125

Form 125 is an electronic fill-in form used by the District Office when transferring client records from one office to another or to State Office. The electronic form fill-in features enable the form to be completed in a legible and efficient manner. For ease of completion for the Case Technician, the DFA Administrative Supervisor’s name and District Office address are pre-entered in the "From" box in the electronic version. Once the form is completed electronically, it is printed and serves as a communication document and receipt for the sending and receiving offices. The form is completed by the Case Technician responsible for the case and signed off by supervisory staff. Information on the form is provided by DFA or NHEP staff and CHAP Specialists.

The electronic version of Form 125 has been sent to the Manager of Administration of each District Office under separate cover, as explained in the IMPLEMENTATION section of this SR. A hard copy of Form 125 and its instructions are attached to this SR for reference.

Form NHEP125

Prior to release of this SR, there were no formal or uniform procedures for transferring NHEP records from one NHEP Team to another. New Form NHEP125 standardizes the transfer of records. Form NHEP125 is a 3 part NCR document which the sending NHEP Team uses to inform the receiving office of the reason a case is being transferred. Space is also provided on the form to allow the NHEP Team to enter pertinent client information. Forms instructions to NHEP125 explain in detail how the form is to be completed. Form NHEP125 and its instructions are attached for reference.

Teams will be sent an initial photocopied supply under separate cover. As soon as the NCR copies are available from print, a follow-up distribution will be made. In the interim, NHEP Teams may photocopy Form NHEP125 as needed.

FORMS REVISIONS

Both Form 125 and its instructions and Form NHEP240 have been revised as indicated below.

Form 125

The major revision to Form 125 is its electronic form fill-in capabilities. This enables the form to be completed in a clear and legible manner. The "To" box has a drop down menu which enables the sending office to easily access the address of the receiving office. Other changes to Form 125 are noted below.

·   The header has been updated. The term Office of Economic Services has been replaced with the term Division of Family Assistance.

·   References to Employment Support Services (ESS), Social Services (SS), Form 801, Case Action Order, and AFDC have been replaced with references to NHEP Teams, Child Care (CC), New HEIGHTS, and TANF respectively.

·   A column for Healthy Kids has been added to the "Current Status of All Programs" block.

Form 125(i)

Form 125(i) has been revised to reflect usage of Form 125 as an electronic fill-in form. Outdated terms, such as Form 801 and ESS have been replaced with current terminology. Headings for the Case Technician, DFA Administrative Supervisor or Designee and DFA Support Staff have been added to enhance readability and understanding of the forms instructions.

Form NHEP240

Two changes have been made to Section 1 of Form NHEP240. They are as follows:

·   The Job Retention and Barrier Resolution options under the Welfare to Work check-off box have been eliminated, as it is no longer necessary to note these activities on Form NHEP240; and

·   A new check-off box has been added to indicate participation in the Workforce Investment Act (WIA) of 1998. This Act replaced the Job Training and Partnership Act.

IMPLEMENTATION

Revised Form 125 will be used in its new electronic format beginning on the effective date of this SR. The electronic version of Form 125 has been sent to the Manager of Administration (MOA) of each District Office under separate cover. The MOA has been instructed to customize the form for District Office use by filling in the "To" box with the District Office address, and to save the document as a template in a shared drive for District Office use. MOA’s must alert DFA Supervisors and other DFA staff when the form has been customized and saved to the shared drive.

Although some hard copies of revised Form 125 will be retained in Stock Control, these copies are only to be used on an emergency basis. Upon entry of the electronic copies of revised Form 125, dated 11/00, to the shared drive, District Offices must destroy or recycle all previously dated versions.

New Form NHEP125 will be used in photocopied version as of the effective date of this SR, and will be used in NCR version as soon as NCR versions are printed and distributed.

Current supplies of Form NHEP240 may be used until revised NCR Form NHEP240 is printed and distributed. Upon receipt of the revised versions, the old versions must be destroyed.

CLIENT NOTIFICATION

No client notification is planned, as the forms released in this SR are administrative documents.

TRAINING

No training is planned.

POSTING INSTRUCTIONS

DISPOSITION

This SR may be deleted or destroyed once its contents have been noted and its posting instructions carried out.

DISTRIBUTION

This SR will be distributed according to the electronic distribution list for Division of Family Assistance policy releases. This SR will be available for agency staff in the On-Line Manual Library, and for public access on the Internet at http://www.dhhs.state.nh.us/PMIndex.htm, effective December 1, 2000.

This SR will be distributed under separate cover to all hard copy holders of the Forms Manual.

DFA/SJC:s

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CERTIFICATE OF DESTRUCTION

I hereby certify that all copies of Form 125, dated August 1995/SR 95-39 were destroyed or recycled upon receipt of electronic form fill-in versions of Form 125 dated November 2000, SR 00-50.

Administrative Manager:_____________________ District Office: _________________

Please return this to Stock Control, 6 Hazen Drive, upon receipt of the electronic version of revised Form 125.