Template / Form

How can organizations evaluate their youth oriented programs? One way California is doing this is through surveys given to attendees of the Youth Organizing Disabled and Proud Seminar. Attached are sample letters, surveys and permission forms needed to survey attendees. See also, "Disability History Campaign-Presentation and Resources" for more information about the seminar and "Disability History Week-Activities" for sample training activities.

View two screening tools developed for Rhode Island’s PersonalChoice program. The PersonalChoice Participant Self-Assessment is designed to assess whether the applicant possesses the ability to self-Direct and manage his or her own care. The representative screen details requirements for the role and includes screening questions. These forms can serve as templates for other states developing similar participant-directed initiatives.

These forms were developed for the Personal Preference program which began as part of a national research and demonstration project whose goal was to find new ways for individuals to receive Medicaid Personal Care Assistance (PCA) services. This form was used to assess the participant’s level of functioning and potential risk reduction factors. Scaling includes questions about living arrangements, medications, communication and mobility.

View two forms developed for Rhode Island’s PersonalChoice program. One lists the participant’s rights and responsibilities, and the other is a designation form authorizing a representative to serve the participant. These forms can serve as templates for other states developing similar participant-directed initiatives.

How is California empowering their youth with disabilities? One way is through the Youth Organizing Disabled and Proud Seminar which connects youth with disabilities to each other, organizations, resources and opportunities. The attached activities and their corresponding samples are from the Seminar. Review "Disability History Campaign-Presentation and Resources" and "Disability History Week-Surveys" for more information and surveys and permission samples from this seminar.

Find helpful documents developed for the PersonalChoice program. Included are a flowchart of the referral/intake/enrollment process, Advisement Agency Certification Standards, a Training Manual and Quick Start Guide designed to give participants an overview of the program and their roles and responsibilities (including information on service and spending plans, communication tips, and information about working with PersonalChoice support agencies), and a Spending Plan template.

View a tool used by New Mexico’s Mi Via program to manage risk. The program is available to individuals who are eligible to receive long-term services through one of the four Medicaid waivers. This form is negotiated with the participant to identify areas of concern and potential pathways for intervention.

How are states addressing MIG benefits planning? The Hawaii Benefits Information Network hosted a ceremony for Benefits Planning Certificate Training graduates and officially launched the Hawaii Benefits Information Network. The continuing education slides for this program are attached below, as well as a sample Certificate which shows certification in Hawaii Benefits Planning Certificate Training and could serve as an example for other states.

How are states empowering youth with disabilities? Through the Youth Organizing Disabled and Proud Seminar, California is working to connect youth with disabilities to each other, organizations, resources and opportunities. Attached are some of the training materials and resources from the Seminar. See also "Disability History Week-Activities" for sample training activities and "Disability History Week-Surveys" for surveys and permissions samples from this seminar.

An individuals’ transition to an employment pilot project can involve a tracking system outlining the different programs and the particular enrollment status. The District of Columbia created a data spreadsheet for NCC Conversion to their Employment Pilot Project, financed by the MIG grant. This information is a “snapshot” of a client's status at the first of the month. A draft of this form is attached, which could be helpful to other states looking to start a similar program.