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

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.