Form 5-6602 Individual Self-Sufficiency (ISP) / Case Plan

Financial Assistance & Social Services Program, 25 CFR 20

BIA_Form_5-6602

Information for ISP

OMB: 1076-0017

Document [docx]
Download: docx | pdf

OMB NO. 1076-0017

U.S. DEPARTMENT OF THE INTERIOR EXP:

BUREAU OF INDIAN AFFAIRS BIA 5-6602



Redetermination Date (3 months: ISP)/ (6 months: Case Plan) Date GA Recipient met ALL goals (mm/dd/yyyy)

(mm/dd/yyyy)/ Initials: _______/_______/_______ / _____________ (mm/dd/yyyy)/ Initials: _______/_______/_______ / __________

INDIVIDUAL SELF-SUFFICIENCY (ISP)/ CASE PLAN (25 CFR Part 20)

ISP / Case Plan [Check all that Apply]

Name of Client: (Last, First, Middle): _________________________________________________ Date of Plan: ______/______/______

What is/are your goals to achieve self-sufficiency?

Short-Term Goals: Long-Term Goals:


BARRIERS TO CLIENT

STRENGTHS OF CLIENT

Health

Mental Health

Substance Abuse Dependency

Age Factors

Disabilities

Lack of/ Limited Transportation

Lack of/ Limited Education

Criminal History

Limited/ No Work History

No Job Skills

No Driver’s License

Social Isolation

Limited/No Jobs Available

Homeless

Other: ________________________

Identify strengths the client possesses:

STEPS NEEDED TO ACHIEVE SELF-SUFFICIENCY

WORK ACTIVITIES

Job Search

Volunteer Work Experience

Job Sampling or Job Shadow

On-the-Job Training

Employment Counseling

Registration with Local Job Service

Job Readiness

Other: _________________________

EDUCATION/ TRAINING

High School Diploma

GED

ESL (English as 2nd Language)

Adult Vocational Training

Literacy Improvement

Higher Education

Other: _________________________

OTHER ACTIVITIES

Life Skills Activities

Parenting Skills

Childcare Assistance

Child Support

Substance Abuse Treatment

Counseling

Driver’s License Reinstatement

Dental/Health Care

Other: ________________________

CASE PLAN

SSA Application

Medical Report

Decision Letters

Legal Assistance

Care for Child Under Age 6

Other: ______________________


SELF SUFFICIENCY ACTION PLAN & GOALS

GOAL #1



Goal #1 Revised

ACTION STEPS FOR GOAL #1

DATE TO BE ACHIEVED

DATE COMPLETED

1.



2.



GOAL #2




Goal #2 Revised



ACTION STEPS FOR GOAL #2

DATE TO BE ACHIEVED

DATE COMPLETED

1.



2.



SOCIAL SERVICES WORKER’S ACTIVITY WITH TIMEFRAME (25 CFR 20.318)

DATE TO BE ACHIEVED

DATE COMPLETED

1.



2.




_____ By initialing you understand that the purpose of the Individual Self-Sufficiency Plan (ISP) is to meet the goal of employment through specific action steps and I am required to follow the steps developed in the ISP. I understand that I must participate in work activities and/or other activities and referrals developed in this plan that will promote my self-sufficiency. Failure to follow through with the ISP may constitute suspension from the General Assistance Program for a period of at least 60 days but not more than 90 days. I also understand that if there are any changes to be made that I will contact my Case Worker in a timely manner to ensure my success in the General Assistance Program.

_____ By initialing you understand that the purpose of the Case Plan is to follow through with goals listed: (i.e.) Accessing other resource programs, keeping medical appt., etc. Failure to follow through with the steps identified in the Case Plan may constitute suspension from the General Assistance Program.


_____________________________________ _______________ ________________________________________ _______________

GA Recipient Signature Date Signed Social Services Worker Signature Date Signed




__________ __________________________________________________ _________ _____________________________________________

Date Signature of Applicant Date Signature of Social Service Worker



________ ___________________________________

Date Signature of Bureau Line Office (if applicable)


















Privacy Act Statement

25 CFR Part 20 and 25 U.S.C. 13 authorize the collection of this information. The information is confidential and is never disclosed without written clearance and consent of the applicant. The primary use of this information is to determine eligibility for financial assistance and services from the Bureau of Indian Affairs (BIA) Child Welfare, Burial, and Disaster programs. Additional disclosures of the information may be to other BIA or tribal officials in the conduct of their official duties pertaining to the application for financial assistance or services, or in the conduct of program review and to the Office of the Inspector General or the General Accounting Office when conducting an audit of BIA programs, or local law enforcement agency when the Agency becomes aware of violation or possible violation of civil or criminal law, and to the General Services Administration in connection with its responsibility for records management. This information will be entered into the BIA, Social Services system of records which can be obtained upon request from Chief, Division of Social Services, 1849 C Street, NW, MS-3647-MIB, Washington, DC 20240. No record contained therein may be disclosed by any means of communication to any person, or to another agency, except pursuant to a written request by, or with prior written consent of the individual to whom the record pertains. Executive Order 9397 authorizes the collection of your Social Security number. Furnishing the information is voluntary but failure to do so may result in disapproval of your application. If the BIA uses the information furnished on this form for purposes other than those indicated above, it may provide you with an additional statement reflecting those purposes.


Paperwork Reduction Act Statement

The information is being collected to determine applicant eligibility for financial assistance and services and to provide Bureau of Indian Affairs (BIA) managers with information for program planning, reporting and utilization. Response to this collection is required to obtain a benefit(s) required in 25 CFR 20. A Federal Agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Public reporting for this form is estimated to average 1 hour per response, including the time for reviewing instructions, gathering and maintaining data, and completing the form. Direct comments regarding the burden estimate or any other aspect of this form to: Office of Regulatory Affairs & Collaborative Action - Indian Affairs, Information Collection Clearance Officer, 1001 Indian School Road NW, Suite 229, Albuquerque, NM 87104.



File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorFry, Ashley D
File Modified0000-00-00
File Created2024-07-25

© 2024 OMB.report | Privacy Policy