minnesota government data practices act …9e2cf57f...9/2016 page 1 minnesota government data...
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9/2016 Page 1
MINNESOTA GOVERNMENT DATA PRACTICES ACT
INVENTORY OF NOT PUBLIC DATA ON INDIVIDUALS
Yellow Medicine CountyResponsible Authority – Rae Ann Keeler-AusYellow Medicine County Family ServicesDirector
Department/DivisionFamily Services – Social Services
Name of Form,Record, File, System,
or Process
Description(Purpose, what it collects, in terms understandable by general public)
Classification Statute Designee
YMCFSC primarily utilizes forms provided by the MN Department ofHuman Services for data collection. Please refer to this website for the
most current MN DHS inventory of forms.https://edocs.state.mn.us/lfserver/Public/DHS-6557-ENG
DHS Notice of social services action Private M.S. 13.46, subd 2Melissa Helgeson,Stacey Steinbach
Social Services Supervisors
Calculation of the parental fee PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS Notice of privacy practices and completed acknowledgement PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS Tennessean Warning PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
YMC Completed consent for release and exchange of information PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
YMC Completed death and serious injury reporting form PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
YMC CDCS – plan review/approval – fillable and written PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
YMC CDCS – revision request form – fillable and written Private M.S. 13.46, subd 2 Melissa Helgeson,
9/2016 Page 2
Stacey SteinbachSocial Services Supervisors
YMC CDCS – plan review PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS CDCS – community support plan and budget PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS CDCS – community support plan – Rule 185 compliant – DD PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
SSIS Intake – social service referral PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
SSIS Notification to school to interview child PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS Completed data privacy notification PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS Alternative Response family assessment worksheet PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
SSISNotice of Determination Letter (NOD) Alleged Offender – NO Determ orCPS Needed
PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
SSISNotice of Determination Letter (NOD) – Alleged Offender –Abuse/Neglect OCCURRED CPS NOT
PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
SSISNotice of Determination Letter (NOD) – Alleged Offender –Abuse/Neglect OCCURRED -CPS NEEDED
PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
SSISNotice of Determination letter (NOD) – Alleged Offender – NO Determ –CPS Needed
PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
9/2016 Page 3
SSISNotice of Determination Letter (NOD) – Offending parent – NODetermination – CPS Needed
PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
SSISNotice of Determination letter (NOD) – Offending Parent – NODetermination – CPS NOT Needed
PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
SSISNotice of Determination Letter (NOD) – Offending Parent – NODetermination – CPS NOT Needed
PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
SSISNotice of Determination Letter (NOD) – Offending Parent –Abuse/Neglect OCCURRED – CPS Needed
PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
SSISNotice of Determination Letter (NOD) – Non-Offending Parent –Abuse/Neglect OCCURRED – CPS NOTE Needed
PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
SSIS Voluntary Placement Agreement PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Family Safety Plan (alternative response) Private
M.S. 13.46, subd 2 Melissa Helgeson,Stacey Steinbach
Social Services SupervisorsSocial Services Supervisors
MH Screening Notice PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Full Disclosure statement – conc. plng. – parents of kids in FC PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Client/parent safety plan PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Concurrent planning full disclosure statement PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Child foster home licensing review Private M.S. 13.46, subd 2 Melissa Helgeson,
9/2016 Page 4
YMC AFC – Incident report PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS AFC – relicensing – corporation- applicaiton PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Foster parent evaluation of child placement PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Clothing Inventory PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Stacey SteinbachSocial Services Supervisors
FC – Letter of Reference PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Foster home relicensing /alternate year review data PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Family foster care training and skills form PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS Individual resident placement agreement PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CFC – difficulty of care rating sheet PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
AFC – program abuse prevention plan PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CFC – incident report PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
9/2016 Page 5
Initial corp. lic. Checklist PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS AFC – relicensing checklist PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CFC – record of training PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS Purchase of service agreement PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Rule 203 lic./relicensing checklist PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
AFC grievance policy PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Corp. CFC – relicensing/alt. year checklist (dict. outline) PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Completed AFC – home drug and alcohol policy agreement PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
YMC AFC – Initial Licensing checklist PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
YMC AFC individual abuse prevention plan PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS Foster care correction order (MIGHT BE PUBLIC!) PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS Adult foster care caregiver training record PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey Steinbach
9/2016 Page 6
Social Services Supervisors
DHS Physician’s statement – medication admin assistance PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Family disaster plan PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Release of info. for CC licensing “background” study PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Permission to administer medication PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Family child care – placement list PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CC – accident report PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Completed relicensing materials letter – FCC PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Parent Evaluation PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Child care record of training PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Reference for FCC licensing PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Questionnaire for CC applicants PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
YMC Request for variance – FCC Private M.S. 13.46, subd 2 Melissa Helgeson,
9/2016 Page 7
Stacey SteinbachSocial Services Supervisors
YMC Completed FCC – lic. previously licensed in your county letter PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
YMC Variance log PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
YMC Criminal background study completion letter – not disq. PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
YMC Background study documentation form PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
YMC Completed unlicensed family child care letter PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS Child care initial licensing checklist PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS Completed your right to appeal PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Standard ROI Authorization to Release Rule 25 assessment PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
BSC – 199DHS – 3979
Completed data practices rights advocacy-CD aka Tennessen warning) PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
YMC Prepetition screening report PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
YMC Data practices rights advisory (Tennessen warning) PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
9/2016 Page 8
YMC Close case request letter PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
YMC Case note documentation PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
YMC Completed side effects letter – Mental Health PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
YMC Clinical Supervision- Mental HealthM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Provider Diagnostic Assessment PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
YMC Closing Summary PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
YMC Complete host county notification letter (CADI) PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
YMC FSG – prog. Documentation of annual expenditures PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS ISP plan – long form PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Provider’s risk management assessment and plan PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
YMC FSG – application – attachment B PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
9/2016 Page 9
YMC FSG – budget of subsidized expenses PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
75000-61 Service agreement PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS CSSP – transmittal svs. amendment PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Provider Physical exam form PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS DD Unit –CSSP & face-to-face tracking sheet PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
SSIS Adult intake social service referral PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS Completed Tennessen warning PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
YMC Guardianship/conservatorships form PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
YMC VA/DD TCM eligibility determination worksheet PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Court Completed physician’s cover letter for guardianship PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
YMC AP Assessment forms PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
SSIS Case Closing Summary/Investigative Summary PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey Steinbach
9/2016 Page 10
Social Services Supervisors
SSIS VA Investigation PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
SSIS Completed false findings letter PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
SSIS Completed inconclusive findings letter PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
SSIS Completed no determination letter PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
SSIS Completed substantiated findings letter PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
ASQ – NA ASQ -3 2 mo. Questionnaire PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
ASQ – NA ASQ -3 4 mo. questionnaire PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
ASQ – NA ASQ -3 6 mo. questionnaire PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
ASQ – NA ASQ -3 8 mo. questionnaire PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
ASQ – NA ASQ -3 10 mo. questionnaire PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
ASQ – NA ASQ -3 12 mo. questionnaire PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
ASQ – NA ASQ -3 14 mo. questionnaire Private M.S. 13.46, subd 2 Melissa Helgeson,
9/2016 Page 11
Stacey SteinbachSocial Services Supervisors
ASQ – NA ASQ -3 16 mo. questionnaire PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
ASQ – NA ASQ -3 18 mo. questionnaire PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
ASQ – NA ASQ-3 20 mo. Questionnaire PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
ASQ – NA ASQ -3 22 mo. Questionnaire PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
ASQ – NA ASQ -3 24 mo. Questionnaire PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
ASQ – NA ASQ -3 27 mo. Questionnaire PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
ASQ – NA ASQ -3 30 mo. Questionnaire PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
ASQ – NA ASQ -3 33 mo. Questionnaire PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
ASQ – NA ASQ -3 36 mo. Questionnaire PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
ASQ – NA ASQ -3 42 mo. Questionnaire PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
ASQ – NA ASQ -3 48 mo. Questionnaire PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
9/2016 Page 12
ASQ – NA ASQ -3 54 mo. Questionnaire PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
ASQ – NA ASQ -3 60 mo. Questionnaire PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CH-NA Children’s Mental Health Referral Form PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Court-NA Notice child returned to care parent or legal custodian PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS – 0033 Appeal to state agency PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS - 0139 Agreement Between Foster Parents and Placement AgencyM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS –0250
MN DHS Div. of Licensing Family Systems Application PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS – 0312Adoption Placement agreement for child under state guardianship(2010)
PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS – 0644 Home Safety Checklist PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS – 0968 Adoptive Applicant Registration State Adoption Exchange PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS – 1542D Interstate Compact – Placement of Children Summary PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS – 1715 Family day care admission and arrangements PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey Steinbach
9/2016 Page 13
Social Services Supervisors
DHS – 1995 Physician’s Report PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS – 2140 Application for Social Services PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS – 2424 Request for Fire Inspection PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS – 2720 Floor and Escape Plan PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS – 2780 Client Placement Authorization - CCDTF PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS – 2794 Rule 25 Assessment and Placement Summary PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS – 0188 Report to court petition for adoption PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS – 0178 Report of Adoptive Placement PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS – 3067 DD Screening Document PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS – 3070 Service Agreement PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS – 3141 Variance Request PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS – 3152 Completed TCM data transmittal Private M.S. 13.46, subd 2 Melissa Helgeson,
9/2016 Page 14
Stacey SteinbachSocial Services Supervisors
DHS – 3218 Emergency relative FC license application PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS – 3235 Background and Health History PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS – 3243 CEP Intake form – VA maltreatment report – disclosure PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS – 3324 Div. of Lic. Family Systems Unit Application PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS – 3428A MN LTCC Services Assessment form: SW section PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS – 3478Title IV-E Foster Care Supplement of the Health Care ProgramsApplication
PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS - 3614 CAC Application/Reassessment Support Plan PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS – 3848 Related Conditions Checklist (DD) PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS - 4268Association of Administrators of the Interstate Compact on thePlacement of Children
PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS – 4007 County of Financial Responsibility PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS – 4147ACase Manager’s Guide to Determining ICF/DD Level of Care for ICF/DDand DD Waiver Services
PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
9/2016 Page 15
DHS – 4258A MN Adoption and Foster Care Application – Home Study PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS – 4258B MN Adoption and Foster Care Individual Fact Sheet PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS – 4258C Agency Home Study Checklist for Eligibility PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS – 4258D Home Study Assessment (fillable) PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS – 4258E Home Study Assessment Update (fillable) PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS – 4258F Family Disaster Plan PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS – 4266 Interstate Compact – placement – children – request PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS – 4267 Interstate Compact – Placement – children – report placement status PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS – 4369 Notice of Social Service Action PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS – 4689A Screening Deletion Request – DD PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Monthly Crib Inspection Form PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS – 5017 Summary of Diagnostic Findings Related to PASARR Mental Illness PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey Steinbach
9/2016 Page 16
Social Services Supervisors
DHS – 5178 Emergency Relative Placement – FC Referral form PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS – 5204 Rule 25 Assessment PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS – 5225 Data Practices Agreement (ICWA) PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS – 5227 ICWA Notice to Tribe of Services to an Indian Child PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS - 7216 Physician Directive for alternative infant sleep position PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS – 5883 Substantiated perpetrator reporting form PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS – 6123 State Medical Review Team Referral for Disability Determination PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS – 6124 Authorization to Disclose Protected Health Information PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS – 6125 Adult Disability Worksheet PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS – 6249 LOCUS Recording Form PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS Consent/Authorization for release of information PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS –NA Functional Assessment (AKA mental health scale) Private M.S. 13.46, subd 2 Melissa Helgeson,
9/2016 Page 17
Stacey SteinbachSocial Services Supervisors
DHS – NA Immediate risk of harm determination worksheet PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS – NA Individual abuse prevention plan – IAPP PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS – NA Req. – reconsideration of disqualification form PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS – NA Rule 203 AFC lic. checklist consolidated stds. sites PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
MED – NA SNBC – PIN Health Risk Assessment PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
MDH Certificate of adoption PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
MDH Child Care Immunization Record PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
MDH MN Birth Record Appl. Certified Copy PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
MN-SFM Owner Permission – State Fire Marshall Inspection PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
MNTS MN Telephone Svc. Discount Application PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Ombudsman Death Report PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
9/2016 Page 18
Ombudsman Death – Serious Injury fax cover PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Ombudsman Serious Injury Report PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
PSC Pediatric Systems Checklist PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Salvation Army Agency Referral Form PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
SSIS AP – VA Investigation PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
SSIS CH MH – advisory and notice of rights – SED child in vol. placement PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
SSISCH MH – referral – review – vol. placement – DD or emotionallydisturbed children (SED)
PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
SSIS CP – case summary /closing PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
SSIS CP – checklist for youth 16+ (in care) PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
SSIS CP – court report 90 – day TBR review – child 16 and over PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
SSIS CP – court report 90- day TPR review – child under 16 PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
SSIS CP – court report – child at home PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey Steinbach
9/2016 Page 19
Social Services Supervisors
SSIS CP – court report – child at home ICWA PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
SSIS CP – court report – child out of home PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
SSIS CP – court report – child out of home and over 16 PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
SSIS CP – court report – child out of home and over 16 - ICWA PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
SSISCP – court report – child out-of-home and under 16
PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
SSIS CP – court report – child out-of-home and under 16 – ICWA PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
SSIS CP – court report – informal review order PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
SSISCP – court report – informal review – vol. placement – DD/EmotionallyDisturbed
PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
SSISCP – disposition of child protection report – notice to mandatedreporters
PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
SSIS CP – Family Safety Plan PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
SSIS CP – Request for Police Records PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS DD – CSSP – individual service plan (long form) Private M.S. 13.46, subd 2 Melissa Helgeson,
9/2016 Page 20
Stacey SteinbachSocial Services Supervisors
DHS DD –CSSP Individual service plan – Form B (short form) PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
SSIS Intake – CP Case Assessment PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
SSIS Intake – CP screen out maltreatment/mandated reporter – screener PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
SSIS Intake – CP screen out maltreatment/vol. reporter screener PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
SSISIV-E – Title IV-E Foster Care 6 month continuing reimbursementchecklist
PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
YMC MH – Commitment Report 1: 60-90 day treatment report PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
SSIS MH – crisis plan PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
SSIS MH – functional assessment PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
MH – individual community support plan PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
SSIS MH – prepetition screening report PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
MH SOC1 – court report : stayed order of commitment report (90 day) PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
9/2016 Page 21
MH SOC3 – court report: request extension of stayed order ofcommitment report
PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
MH SOC4 – court report: request revocation of stayed order ofcommitment report
PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
MH SOC5 – court report : extension of stayed order of commitmentreport
PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Placement Team – child –respite care request PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Social Services Form IV-E Eligibility Form PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Social Services Form Relative Search Form PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Adoption Delegation of Powers by Parent PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Adult Foster Care AFC Case Notes PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Adult Foster Care Incident Report Form PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Adult Foster Care Individual Abuse Prevention Plan PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Adult Foster Care Individual Resident Placement Agreement PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Adult Foster Care Training Log PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey Steinbach
9/2016 Page 22
Social Services Supervisors
Adult Foster Care Fire Drill Log PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Adult Foster Care Grievance Policy PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Child Foster Care Consent for a Background Check Child Foster Care/Adoption PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Child Foster Care Clothing Inventory and Record PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Child Foster Care Data Privacy and Confidentiality PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Child Foster Care Discipline Policy PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Child Foster Care Emergency Procedures PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Child Foster Care Initial Foster Care Licensure Checklist PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Child Foster Care Mandated Reporting Form PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Child Foster Care Medical Assistance Mileage Reimbursement PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Child Foster Care Monthly Visits for 6 Months after Licensure PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Child Foster Care Placement Record Private M.S. 13.46, subd 2 Melissa Helgeson,
9/2016 Page 23
Stacey SteinbachSocial Services Supervisors
Child Foster Care Reference Form PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Child Foster Care Training Log PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Child Foster Care Variance Request PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Licensing (General) Chemical Use Policy PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Licensing (General) Complaint Log PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Licensing (General) Correction Order PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Placement Clothing Allowance Request PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Placement Out of Home Placement Checklist PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Respite Care Respite Consent for Background Check PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Supervised Visitation Report of Suspected Abuse or Neglect PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Child Care Licensing Background Consent Form PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
9/2016 Page 24
Child Care Licensing Reference Form PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Child Care Licensing Your Privacy Rights PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Child Care Licensing Provider’s Agreement PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Child Care Licensing Child Abuse/Neglect Reporting (Mandated Reporting) PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Child Care Licensing Day Care Licensing Home Study PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Child Care Licensing Provider Policy Checklist PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Child Care Licensing Serious Injury Report Form PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Child Care Licensing Log of Monthly Fire Drills PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Child Care Licensing Training Logs PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Child Care Licensing Record of Background/Chemical Use Policy/training requirements PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Child Care Licensing Variance application PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Child Care Licensing Request for Reconsideration of a Disqualification PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey Steinbach
9/2016 Page 25
Social Services Supervisors
Child Care Licensing Variance due to Well Water Test PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Child Care Licensing Emergency Phone Numbers Records PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CCAP Child Care Assistance Program Application Letter PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS – 3550 MCCAP Application PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CCAP DHS – 3551 Do you need help paying for child care? Brochure PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CCAP DHS – 3979 Notice of Privacy Practices PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CCAP DHS – 3163B Referral to Support and Collections PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CCAP DHS – 2338 Cooperation with Child Support Enforcement PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CCAP CCAP Redetermination Cover Letter PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CCAP DHS – 5274 CCAP Redetermination Form PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CCAP DHS – 2402 Change Report Form PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CCAP DHS – 5190 CCAP Licensed Provider Registration Acknowledgement Private M.S. 13.46, subd 2 Melissa Helgeson,
9/2016 Page 26
Stacey SteinbachSocial Services Supervisors
CCAP DHS – 5191 CCAP Licensed Exempt Provider Registration and Acknowledgement PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CCAP DHS - 5192 CCAP Legal Nonlicensed Provider Registration and Acknowledgement PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CCAP DHS – 4079 Child Care Provider Responsibilities and Rights PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CCAP DHS – 3985 Notice of Privacy Practices for Child Care Providers PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CCAP DHS – 3552 Direct Deposit for Minnesota Child Care Assistance Program PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CCAP DHS - 5318 CCAP Financial Tracking Form PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CCAP DHS – 5192AHealth and Safety Resource List for Parents and Legal NonlicensedProviders
PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CCAP DHS – 5193 CCAP Authorization for Release of Background Study PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CCAP DHS – 6419CCAP Training Requirements for Legal Nonlicensed Family Providers –Questions and Answers
PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CCAP DHS – 5367CCAP Parent Acknowledgment When Choosing a Legal NonlicensedProvider
PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CCAP DHS – 4795 CCAP Quality Differential Rate Request Form PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
9/2016 Page 27
CCAP W-9 PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CCAP DHS – 4018 Important Information for Child Care Providers PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CCAP DHS – 5242 Child Care Assistance Notice of Decision PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CCAP DHS – 5260 CCAP Child Care Provider Guide PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CCAP DHS – 3131A CCAP Provider Notice of Intentional Program Violation – Waiver of ADH PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CCAP DHS - 5523 Child Care Assistance Billing Form PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Service Authorization Provider PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CCAP DHS – 3429A CCAP Disqualification Consent Agreement PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CCAP DHS – 4003 Child Care Status Transmittal Update to Child Support PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CCAP DHS – 6475 CCAP Parent Request for In-home Child Care PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CCAP DHS – 3627Important Information about Your Request for a Child Support GoodCause Exemption
PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CCAP DHS – 3628 Denial of Good Cause Claim PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey Steinbach
9/2016 Page 28
Social Services Supervisors
CCAP DHS – 3629 Notice of Good Cause Approval PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CCAP DHS – 3630 Notice of Good Cause Redetermination PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CCAP DHS – 3633 Notice of Good Cause Approval for Redetermination PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CCAP DHS – 3631 Notice to End Good Cause PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CCAP DHS – 3429 Disqualification Consent Agreement PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CCAP DHS – 5223D Combined Application – Child Care Addendum PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CCAP DHS - 2120 Household Report Form PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CCAP DHS – 2646 Financial Aid Information Form PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CCAP DHS – 2919A Verification Request Form A PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CCAP DHS – 2919B Verification Request Form B PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CCAP DHS – 3336 Self-employment Report Form PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CCAP DHS – 4794 CCAP Program Change Report Form Private M.S. 13.46, subd 2 Melissa Helgeson,
9/2016 Page 29
Stacey SteinbachSocial Services Supervisors
CCAP DHS – 5223 Combined Application Form PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CCAP DHS – 5223C Combined Application Form Addendum PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CCAP DHS – 4194 CCAP Special Needs Rate Variance Request/Parent & Provider PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CCAP DHS – 4195 CCAP Special Needs Rate Variance Request – County Recommendation PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CCAP DHS – 5588 Notice of Decision – Denial PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CCAP DHS – 5588A Notice of Decision – Termination PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CCAP DHS – 5671 Basic Sliding Fee Monthly Waiting List PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CCAP DHS – 6035A Proof of Residence PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CCAP DHS – 6413 Co-payment Schedule PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CCAP DHS – 6441B Standard Maximum Rates PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS – 6443 Maximum Registration Fees PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
9/2016 Page 30
DHS – 0033 Appeal Request to State PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CCAP Service Authorization Family PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CCAP Education/Employment PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CCAP Employment Services Plan PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CCAP Redetermination Cover Letter PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CCAPEligibility Approval –Opening/Closing/Re-Opened/Redetermination/Denial/Co-pay Change
PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CCAPSpecial Letter for Information Request –Identity/DOB/Relationship/Citizen Status/Residence/Activity/Financial
PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CCAP CCAP Memo PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CCAP Notice of Intentional Program Violation PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CCAP Request for ADH Hearing PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CCAP Notification of Overpayment to Claims Department PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CCAP Client Repayment Agreement PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey Steinbach
9/2016 Page 31
Social Services Supervisors
CCAP Client Notice of Recoupment PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CCAP Client Notice of Repayment PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CCAP Client Notice of Revenue Recapture PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CMH Functional Assessment PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CMH CASSI PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CMH SDQ PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CMH Individual Family Community Support Plan PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CMH Respite /Foster Care Child Information PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CMHChecklist for Guide Case Manager Activities in Qualifying a Child forChildren’s Mental Health Case Management Services
PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CMH Client Rights and Responsibilities PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CMH Notice of Privacy Practices PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CMH Authorization to Release Information List Private M.S. 13.46, subd 2 Melissa Helgeson,
9/2016 Page 32
Stacey SteinbachSocial Services Supervisors
CMH Clinical Supervision of Case Manager PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CMH Prime West TCM Service Authorization Request Form PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CMH Consent for Release of Information PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CMH DHS-2140 Application for Social Services PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CMH CMH Determine Eligible Letter PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CMH Closing Letter PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CMH Diagnostic Referral Letter PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CMH Notification of Availability of Children’s Mental Health Services PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CMH DHS-1776 Voluntary Out of Home Placement Agreement PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CMH Pre-placement Review Team Meeting PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CMH Agency Notification of Placement PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
9/2016 Page 33
CMH Notice to Parents of Financial Responsibility (placement) PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CMH Difficulty of Care Assessment Schedule PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CMH DHS-6126 Children’s Disability Worksheet (SMRT) PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CMH DHS -6123 SMRT Referral for Disability Determination PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CMH SMRT Request for Child Medical Examination PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CMH CTSS Referral PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CMH Intensive In-home Counseling Referral PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CMH Family Group Decision Making Referral PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CMH Delegation of Powers by Parent PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CMH CSIS Vendored Service Voucher PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CMH Signs of Safety Assessment and Planning Form PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CMH Signs of Safety Harm and Danger Statement PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey Steinbach
9/2016 Page 34
Social Services Supervisors
CMH Closing Summary PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CMH Relative Search PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CMH PSOP Case Plan PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CMH FA Response Summary PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CMH DHS-6349 MHCP Request for Disability Information PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CMH DHS-6124 SMRT Authorization to Release Protected Health Information PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS – Daycare Admissions and Arrangements PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
MDH Immunization PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Yellow Medicine Co.Daycare
Accident Report PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS -Daycare Insurance Notice PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS -7218 Parental Consent for Swaddling an Infant PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Drug and Alcohol Policy (Daycare, Adult & Child Foster Care, FADS) Private M.S. 13.46, subd 2 Melissa Helgeson,
9/2016 Page 35
Stacey SteinbachSocial Services Supervisors
Yellow Medicine Co.Daycare
Fact Sheet PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Fire MarshalFire Marshal Inspection Results (Daycare, Adult & Child Foster Care,FADS)
PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Fire MarshalFire Marshal Inspection Request (Daycare, Adult & Child Foster Care,FADS)
PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS – 2720 Floor and Escape Plan PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Yellow Medicine Co. Furnace Inspection (Daycare, Adult & Child Foster Care, FADS) PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Client Grievance Policy (Daycare, Adult & Child Foster Care, FADS) PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS Home Safety Checklist PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Yellow Medicine Co.Daycare
Permission to AdministerM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS – 1995 Physician’s Report PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Client Program Policies (Daycare, Adult & Child Foster Care, FADS) PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Yellow Medicine Co. Program Plan (Daycare, Adult & Child Foster Care, FADS) PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
9/2016 Page 36
Yellow Medicine Co.,DHS
Provide Agreement (Daycare, Adult & Child Foster Care) PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Yellow Medicine Co. Training Record (Daycare, Child Foster Care) PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Yellow Medicine Co. Video Worksheet - Daycare PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
State Application (Daycare, Adult & Child Foster Care, FADS) PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Yellow Medicine Co. Initial License Checklist (Daycare, Adult & Child Foster Care, FADS) PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Yellow Medicine Co. Relicense Checklist (Daycare, Adult & Child Foster Care, FADS) PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Yellow Medicine Co. Relicense Letter (Daycare, Adult & Child Foster Care, FADS) PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Yellow Medicine Co. Negative Action Parent Letter (Daycare) PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
SSISNegative Action Recommendation Letter (Daycare, Adult & Child FosterCare, FADS)
PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Yellow Medicine Co.,SSIS
Negative Action Provider Letter (Daycare) PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS Correction Order (Daycare, Adult & Child Foster Care, FADS) PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Yellow Medicine Co. Correction Order Letter (Daycare, Adult & Child Foster Care, FADS) PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey Steinbach
9/2016 Page 37
Social Services Supervisors
Yellow Medicine Co. Relicensing Follow-up Letter (Daycare, Adult & Child Foster Care, FADS) PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Yellow Medicine Co.Investigation Form or Information (Daycare, Adult & Child Foster Care,FADS)
PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHSNegative Action Determination (Daycare, Adult & Child Foster Care,FADS)
PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Yellow Medicine Co. Background Study Form (Daycare) PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Yellow Medicine Co. Background Study More Time Needed (Daycare) PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Yellow Medicine Co.,DHS
Clearance Letter (Daycare, Adult & Child Foster Care, FADS) PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS Negative Action Reconsideration (Daycare, Adult & Child Foster Care) PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS Negative Action Appeal (Daycare, Adult & Child Foster Care) PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Client Incident Reports (Child & Adult Foster Care, FADS) PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Yellow Medicine Co. Parent Evaluations and Cover Letter (Daycare) PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Yellow Medicine Co. Client Evaluations and Cover Letter (Child & Adult Foster Care, FADS) PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Yellow Medicine Co. License Recommendation (Daycare) Private M.S. 13.46, subd 2 Melissa Helgeson,
9/2016 Page 38
Stacey SteinbachSocial Services Supervisors
DHS - 0644 Home Safety Checklist Addendum (Child Foster Care) PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Client Discipline Policy (Child Foster Care) PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS – 4258D Home Study (Child Foster Care) PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS – 4258E Home Study Update (Child Foster Care) PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS – 4258B Individual Fact Sheet (Child Foster Care) PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS Statement of Intended Use (Child Foster Care) PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Yellow Medicine Co. Substitute Care Plan (Child Foster Care) PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Yellow Medicine Co. Provider History Update (Child Foster Care) PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Yellow Medicine Co. List of Current Placements (Child Foster Care) PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Yellow Medicine Co. Insurance Verification (Child Foster Care) PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS – 4258C Home Study Checklist PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
9/2016 Page 39
Yellow Medicine Co. Evaluation by Provider (Adult & Child Foster Care, FADS) PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Client Chemical Use Signature Policy (Child Foster Care) PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Yellow Medicine Co.,Client
Placement Forms (Adult & Child Foster Care) PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Yellow Medicine Co.,Client
Discharge Forms (Adult & Child Foster Care) PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Yellow Medicine Co. Annual Contact (Child Foster Care) PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Yellow Medicine Co. Dual License Initial Checklist (Daycare, Adult & Child Foster Care) PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Yellow Medicine Co. Dual Relicense Checklist (Daycare, Adult & Child Foster Care) PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Yellow Medicine Co.,DHS
Crisis 5th Bed Forms (Adult) PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Yellow Medicine Co. Change of Premise Checklist (Daycare, Adult & Child Foster Care) PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS License Checklist (Adult & Child Foster Care, FADS) PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Yellow Medicine Co. Employee Quarterly Report (Child and Adult Foster Care) PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Yellow Medicine Co. List of Current Residents (Child & Adult Foster Care) PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey Steinbach
9/2016 Page 40
Social Services Supervisors
Yellow Medicine Co. Residents for Last 5 years (Child & Adult Foster Care) PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS, Client Program Abuse Prevention Plan (Child & Adult Foster Care, FADS) PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Yellow Medicine Co. Individual Community Support Plan (Adult Mental Health) PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Yellow Medicine Co. Functional Assessment (Adult Mental Health) PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Yellow Medicine Co.Request for Information Letter (Adult Mental Health, Special NeedsBasic Care - SNBC)
PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Yellow Medicine Co.,Program
Referral to a Service (Adult Mental Health, SNBC) PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Yellow Medicine Co. Service Closing Letter (Adult Mental Health) PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Yellow Medicine Co. Crisis Plan (Adult Mental Health, SNBC) PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
SSIS Medication Side Effects Referral (Adult Mental Health) PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
SSIS Diagnostic Assessment Referral (Adult Mental Health, SNBC) PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Yellow Medicine Co. Client Information Sheet (Adult Mental Health, SNBC) PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
Provider Diagnostic Assessment, psychological (Adult Mental Health, SNBC) Private M.S. 13.46, subd 2 Melissa Helgeson,
9/2016 Page 41
Stacey SteinbachSocial Services Supervisors
PrimeWest Care Plan (SNBC) PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
DHS - 2925 Long Term Care Consultation Community Support PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors
CMH DHS-6126 SMRT Children’s Disability Worksheet PrivateM.S. 13.46, subd 2 Melissa Helgeson,
Stacey SteinbachSocial Services Supervisors