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The Office of Human Services Emergency Preparedness and Response (OHSEPR)

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Disaster Case Management (DCM)

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Disaster Case Management Forms

To view the contents of the forms, please click on the links below.

 
Disaster Case Management Forms Matrix Colors

 

Disaster Case Management Project Forms
Forms Title & Colors Used By Case Managers to: Completed By: Notes

Disaster Case Management Intake

(Bright Yellow)

 Record all pertinent client information, including household information, brief description of disaster related losses and listing of immediate needs. Any member of the disaster case management staff.   

Case Disposition Form and Notes

 

(Gold)

 All cases differ substantially, and some cases may not demand the same system resources or staff hours. Thus, they need not
be subject to the same processing requirements. Some cases can be closed expeditiously, with Information and Referral (I&R) assistance. Others cases require extensive supervision due to the large number of unmet needs and/or the client having no plan to meet basic needs. This form documents case prioritization based on factors such as unmet basic needs, age, and physical condition of the individuals/families.		 Case Manager or Case Management Supervisor. Supervisory oversight is requiredSupervisory sign-off signifies review of the form and approval of the disposition of the case based on the initial assessment, case priority and assignment of a case manager based on staff workload.

Client Consent to the Release of Confidential Information

(White)

 Allows the Administration for Children and Families and/or the Disaster Case Management Program partner to obtain or release information regarding the client. Any member of the disaster case management staff.  

Case Notes

(Light Pink)

 Case Manager or Case Management Supervisor. Remember to start each record with the date and time.  End each entry with a signature and staff member title.  

Services and Referral Tracking

(Light Blue)

 This form is used for two purposes.  Case Managers use this form to document client referrals for service and client utilization of these services.  The form is also used to document agencies/organizations the client is already connected with (pre-disaster and post-disaster). Any member of the disaster case management staff.  

Income Vs. Expenses

(Light Green)

 Staff may use the Income vs. Expense form to assist clients in determining what income they have to work with each month, how to allocate income between paying regular expenses, reducing debts and setting financial goals. Clients and/or any member of the disaster case management staff.  

Closure Summary

(Liliac)

 The Closure Summary requires the Case Manager to undertake a case plan review, complete any missing documentation and review recovery status with the family/individual. Case Managers and Case Management Supervisors The Case Management Supervisor must approve the decision to close or transfer a case.

Disaster Recovery Partnership Plan

(Gray)

 Based on the assessment of client disaster-related needs, the Case Manager will work with the family/client to develop a recovery plan.  The form is used to document the agreed upon goals, objectives and action steps to recover from the disaster.  A client is provided to the family/client. Case Managers and Case Management Supervisors Due to the extent of the documentation, supervisory oversight is required.  Supervisory sign-off signifies review of the recovery plan for realistic, time-specific and measurable recovery goals.

Disaster Assessment

(Bright Green)

 The Disaster Assessment form allows case management staff to obtain more detailed data on disaster losses, unmet needs and emergency assistance. Case Managers and Case Management Supervisors  

Individual Client Assessment

(Light Yellow)

 The Individual Client Assessment is a comprehensive assessment that expands upon the information gathered in the intake. The comprehensive assessment evaluates client resources and strengths, including family and other close supports that can be utilized during service planning. Case Managers and Case Management Supervisors Due to the extent of the assessment, supervisory oversight is required.  Supervisory sign-off signifies review of the content and approval of the quality of the assessment  conducted by the case manager.
Reality Checklist A tool to help clients preparing a disaster recovery plan. Client OPTIONAL FORM

Social Services Screening

(Ivory)

 This screening tool provides a preliminary screening for financial assistance programs administered by the State Department of Social Services.  It does not confirm actual eligibility. Case Manager or Case Management Supervisor. OPTIONAL FORM

Client Satisfaction Form

(Salmon)

 All clients are asked to complete this form (they are not required to complete it, however).  Client feedback about the services they received is used to help improve the Disaster Case Management Program. Any member of the disaster case management staff.  

 

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