Template / Form

How can states better access the needs of their clients as well as their MIG programs? One approach Alaska has taken is instituting the AST test, which is designed to screen for substance abuse, mental illness, and traumatic brain injury. The AST can produce multiple recommendations for more efficient care, state the population needs of each agency, and assist the state in federal reporting requirements. Review a sample screening form which could serve as a template for other states.

How can states more successfully facilitate the employment of their disabled population? One approach Nebraska has taken is gathering information from both clients and worksites with the help of detailed questionnaires. These forms assess the requirements of the job and the needs of the clients, taking into account such factors as transportation, learning style and mobility issues. Three samples of these forms are included here and could prove to be valuable templates for other states.

How is Nebraska using its MIG grant to address the needs of those struggling due to brain injuries? Through a screening tool, and a follow-up questionnaire, the state is working to diagnose these individuals so they may effectively rejoin the workforce. The forms, could serve as a template for other states who wish to do the same, and are available here.

View a presentation given by consultants to explain the VD-HCBS program to veterans once they are enrolled. It delineates the target populations and roles played by the veterans, AAA VD-HCBS staff, and financial management services. Also included is a sample budget sheet.

Ohio's Medicaid Buy-In for Workers with Disabilities (MBIWD) was created to enable Ohioans with disabilities to work and still keep their health care coverage. An application for this program, translated into Spanish, could be useful to consumers as well as state’s with similar needs. The application is provided here.

Rhode Island has developed tools to help determine a PersonalChoice participant’s goals. A Goals Summary worksheet, along with a completed sample worksheet and worksheet directions, are available here.

Self Determination in Long Term Care (SDLTC) is a MI Choice waiver program option. The following forms are used for this program: Budget worksheet, Disenrollment form, Right to Hire form, Right to Hire with Driving Record, Job description form for a PCA/HHA, and Backup Worker form.

This form is used for consumers starting or ending participation in Kentucky's CDO project.

Arkansas developed this template for the development of spending plans by the participant. The plan allows for the calculation of worker hours as well as discretionary cash, transportation, assistive equipment and more.

This is a presentation, from the 2007 Government & Vendor Fiscal/Employer Agent Workshop. An overview of the Consumer Direction Module, a web-based software application for supporting the delivery of self-directed services, is provided here. The CDM is designed to make communication among the program participant, support broker, Fiscal/Employer Agent and state administrator simple and efficient; permit ongoing, timely, and efficient monitoring; and enhance the delivery of self-directed services.