FAMILY INDEPENDENCE ADMINISTRATION Seth W. Diamond, Executive Deputy Commissioner
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1 FAMILY INDEPENDENCE ADMINISTRATION Seth W. Diamond, Executive Deputy Commissioner James K. Whelan, Deputy Commissioner Policy, Procedures and Training Lisa C. Fitzpatrick, Assistant Deputy Commissioner Office of Procedures POLICY BULLETIN # OPE REVISION TO CHILD CARE APPOINTMENT FORMS W-273NN AND W-667C Date: December 18, 2006 This procedure can now be accessed on the FIAweb. Subtopic(s): Forms The purpose of this policy bulletin is to inform Job Center staff that the Child Care Return Appointment (W-273NN) and the Child Care Appointment Confirmation and Contact List (W-667C) have been revised to include references to the: Child Care Provider Enrollment Supplement (W-274W) Enrollment Form for Provider of Legally-Exempt Family Child Care and Legally-Exempt In-Home Child Care (LDSS-4699) Enrollment Form for Provider of Legally-Exempt Group Child Care (LDSS-4700) Samples of the W-273NN and W-667C are attached. Center Directors must ensure that all prior versions of the W-273NN and W-667C are removed from circulation and recycled. Effective Immediately Please use Print on Demand to obtain copies of forms. Attachments: W-273NN W-273NN (S) W-667C W-667C (S) Child Care Return Appointment () Child Care Return Appointment (Spanish) () Child Care Appointment Confirmation and Contact List () Child Care Appointment Confirmation and Contact List (Spanish) () HAVE QUESTIONS ABOUT THIS PROCEDURE? Call then press 2 at the prompt followed by 765 or send an to FIA Call Center Distribution: X
2 Form W-273NN LLF Date: Case Number: Case Name: (I) CHILD CARE IS NEEDED Child Care Return Appointment Please return for the following reason(s) 133S (Participant/Sanctioned Individual) 933S (Applicant) Document required: (II) ADDITIONAL INFORMATION IS NEEDED 133D (Participant/Sanctioned Individual) Check the boxes that apply gfedc Complete and return the child care provider enrollment form(s) provided gfedc Secure and return all documentation listed Documents required: 933D (Applicant) Check all that apply gfedc LDSS-4699 gfedc LDSS-4700 gfedc W-274W I will bring the above-mentioned documentation with me to my new appointment. I will return to this mandatory appointment on: Appointment Date: Time: Telephone: Address: City: State: Zip: Applicant/Participant/Sanctioned Individual's Signature Date Worker's Signature Date
3 Form W-273NN (S) LLF 12/14/06 : Número del Caso: Nombre del Caso: (I) SE NECESITA CUIDADO INFANTIL Cita Subsiguiente de Cuidado Infantil Favor de regresar por la(s) siguiente(s) razón(es) 133S (Participante/Persona Sancionado[a]) Documentos requeridos: 933S (Solicitante) (II) SE NECESITA INFORMACIÓN ADICIONAL 133D (Participante/Persona Sancionado[a]) Marque la(s) casilla(s) que correspondan gfedc Llene y devuelva el formulario de inscripción del proveedor de cuidado infantil gfedc Consiga y devuelva toda la documentación listada Documentos requeridos: 933D (Solicitante) Marque la(s) casilla(s) que correspondan gfedc LDSS-4699 gfedc LDSS-4780 gfedc W-274W Yo traeré toda la documentación antemencionada a mi nueva cita. Yo regresaré a esta cita obligatoria el: de la Cita: Hora: Teléfono: Dirección: Ciudad: Estado: Código Postal: Firma del Solicitante/Participante/Individuo Sancionado Nombre de Trabajador
4 Form W-667C (page 1) LLF Child Care Appointment Confirmation and Contact List Parent/Guardian's Name: Case Number: I understand that I must be employed and/or participating in a work-related activity. I understand that in order for me to obtain or to continue with employment and/or participating in a work-related activity, child care arrangements must be in place for my child(ren) who need(s) care. I will confirm these child care arrangements by keeping the following two child care appointments that were made for me. Provider Name (Worker-Referred) Telephone Number Appointment Date Time Provider Address (Worker-Referred) PROVIDER: Are there any available openings? gfedc Yes gfedc No License No.: Provider's Signature: Reason for not choosing this provider (your reason must include one of the following): gfedc The provider was not open for the days or hours needed or could not care for your child's special needs. gfedc You were unable to get to the provider by car or public transportation. gfedc The provider is not accessible because the travel distance from your home to the child care provider and then to your work activity exceeds 1 hour and 30 minutes. Other: gfedc Provider Name (Worker-Referred) Telephone Number Appointment Date Time Provider Address (Worker-Referred) PROVIDER: Are there any available openings? gfedc Yes gfedc No License No.: Provider's Signature: Reason for not choosing this provider (your reason must include one of the following): gfedc The provider was not open for the days or hours needed or could not care for your child's special needs. gfedc You were unable to get to the provider by car or public transportation. gfedc The provider is not accessible because the travel distance from your home to the child care provider and then to your work activity exceeds 1 hour and 30 minutes. Other: gfedc
5 Form W-667C (page 2) LLF Human Resources Administration Family Independence Administration If I locate a provider on my own, I will write the name, address and telephone number of the provider on the form; in addition, I will have the provider sign the form. Provider Name (Self-Referred) Telephone Number Appointment Date Time Provider Address (Self-Referred) PROVIDER: Are there any available openings? gfedc Yes gfedc No License No.: Provider's Signature: Reason for not choosing this provider (your reason must include one of the following): gfedc The provider was not open for the days or hours needed or could not care for your child's special needs. gfedc You were unable to get to the provider by car or public transportation. gfedc The provider is not accessible because the travel distance from your home to the child care provider and then to your work activity exceeds 1 hour and 30 minutes. Other: gfedc Provider Name (Self-Referred) Telephone Number Appointment Date Time Provider Address (Self-Referred) PROVIDER: Are there any available openings? gfedc Yes gfedc No License No.: Provider's Signature: Reason for not choosing this provider (your reason must include one of the following): gfedc The provider was not open for the days or hours needed or could not care for your child's special needs. gfedc You were unable to get to the provider by car or public transportation. gfedc The provider is not accessible because the travel distance from your home to the child care provider and then to your work activity exceeds 1 hour and 30 minutes. Other: gfedc
6 Form W-667C (page 3) LLF Human Resources Administration Family Independence Administration I will accept one of the Worker- or self-referred openings or seek other licensed or "legal" informal care so I can participate in my activity as noted above. If I use regulated care, I understand I must also obtain all of the needed medical/immunization records so that my child(ren) can start as soon as possible. I will provide a written explanation if I do not accept the two Worker-referred providers or am unable to locate a legal informal provider. I understand that I have an appointment to bring back this form, the child care provider enrollment form(s) (LDSS-4699/LDSS-4700 and/or W-274W) provided to me and other supporting documentation (if applicable) no later than or risk being found ineligible for benefits. (return appointment date) Parent/Guardian's Signature Date JOS/Child Care Worker's Signature Date
7 Form W-667C (S) (page 1) LLF Nombre de Padre/Madre/Tutor: Confirmación y Lista de Contacto de Cita de Cuidado Infantil Número del Caso: Entiendo que debo estar empleado(a) y/o participando en una actividad relacionada con el trabajo. Entiendo que para conservar mi empleo y/o seguir participando en una actividad relacionada con el trabajo, el cuidado de mi(s) hijo(a)(s) debe haber sido previamente concertado. Además, confirmaré los arreglos de cuidado infantil en cuestión acudiendo a las siguientes dos citas de cuidado infantil que se han programado para mí. Nombre del Proveedor (Asignado por Trabajador) Número de Teléfono Cita Hora Dirección del Proveedor (Asignado por Trabajador) PROVEEDOR: Hay vacantes disponibles? gfedc Sí gfedc No Número de Licencia: Firma del Proveedor: Razón por la que no ha escogido a este proveedor (la razón tiene que incluir una de las siguentes): gfedc El proveedor no se encontraba disponible para los días u horas necesitadas o no podía atender las necesidades especiales de su hijo. gfedc Usted no pudo llegar hasta el proveedor mediante carro o transporte público. gfedc El proveedor no es accesible debido a que la distancia desde la casa de usted y al proveedor de cuidado infantil y desde ahí a su actividad de trabajo excede de 1 hora y 30 minutos. Otro: gfedc Nombre del Proveedor (Asignado por Trabajador) Número de Teléfono Cita Dirección del Proveedor (Asignado por Trabajador) Hora PROVEEDOR: Hay vacantes disponibles? gfedc Sí gfedc No Número de Licencia: Firma del Proveedor: Razón por la que no ha escogido a este proveedor (la razón tiene que incluir una de las siguentes): gfedc El proveedor no se encontraba disponible para los días u horas necesitadas o no podía atender las necesidades especiales de su hijo. gfedc Usted no pudo llegar hasta el proveedor mediante carro o transporte público. gfedc El proveedor no es accesible debido a que la distancia desde la casa de usted y al proveedor de cuidado infantil y desde ahí a su actividad de trabajo excede de 1 hora y 30 minutos. Otro: gfedc
8 Form W-667C (S) (page 2) LLF Human Resources Administration Family Independence Administration Si localizo algun proveedor por mi cuenta proporcionaré el nombre, dirección y teléfono del proveedor en el formulario, además haré que el proveedor firme el formulario. Nombre del Proveedor (Asignado Sí Mismo) Número de Teléfono Cita Dirección del Proveedor (Asignado por Sí Mismo) Hora PROVEEDOR: Hay vacantes disponibles? gfedc Sí gfedc No Número de Licencia: Firma del Proveedor: Razón por la que no ha escogido a este proveedor (la razón tiene que incluir una de las siguentes): gfedc El proveedor no se encontraba disponible para los días u horas necesitadas o no podía atender las necesidades especiales de su hijo. gfedc Usted no pudo llegar hasta el proveedor mediante carro o transporte público. gfedc El proveedor no es accesible debido a que la distancia desde la casa de usted y al proveedor de cuidado infantil y desde ahí a su actividad de trabajo excede de 1 hora y 30 minutos. Otro: gfedc Nombre del Proveedor (Asignado por Sí Mismo) Número de Teléfono Cita Dirección del Proveedor (Asignado por Sí Mismo) Hora PROVEEDOR: Hay vacantes disponibles? gfedc Sí gfedc No Número de Licencia: Firma del Proveedor: Razón por la que no ha escogido a este proveedor (la razón tiene que incluir una de las siguentes): gfedc El proveedor no se encontraba disponible para los días u horas necesitadas o no podía atender las necesidades especiales de su hijo. gfedc Usted no pudo llegar hasta el proveedor mediante carro o transporte público. gfedc El proveedor no es accesible debido a que la distancia desde la casa de usted y al proveedor de cuidado infantil y desde ahí a su actividad de trabajo excede de 1 hora y 30 minutos. Otro: gfedc
9 Form W-667C (S) (page 3) LLF Human Resources Administration Family Independence Administration Aceptaré una de las vacantes disponibles asignadas por el Trabajador o por sí mismo buscaré otro cuidado autorizado o informal "legal" para poder participar en mi actividad como se indica más arriba. Si utilizo cuidado reglamentado, entiendo que también debo obtener todos los expedientes médicos o de inmunización necesarios para que mi(s) hijo(a)(s) pueda(n) comenzar lo más pronto posible. En caso de no aceptar a los dos proveedores asignados por el Trabajador, o de no poder conseguir a un proveedor informal ilegal, he de proporcionar una explicación al respecto por escrito. Entiendo que tengo una cita para devolver este formulario, el/los formulario(s) de inscripción el proveedor de cuidado infantil (LDSS-4699-S/LDSS-4700S y/o W-274W [S]) y otros documentos justificativos (si corresponden) a más tardar el más tardar el o de lo contrario me arriesgo a (fecha de cita de regreso) que se me considere inelegible con respecto a beneficios. Firma del Padre/Madre or Tutor Firma del JOS/Trabajador
FAMILY INDEPENDENCE ADMINISTRATION Seth W. Diamond, Executive Deputy Commissioner
FAMILY INDEPENDENCE ADMINISTRATION Seth W. Diamond, Executive Deputy Commissioner James K. Whelan, Deputy Commissioner Policy, Procedures and Training Lisa C. Fitzpatrick, Assistant Deputy Commissioner
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FAMILY INDEPENDENCE ADMINISTRATION Seth W. Diamond, Executive Deputy Commissioner
FAMILY INDEPENDENCE ADMINISTRATION Seth W. Diamond, Executive Deputy Commissioner James K. Whelan, Deputy Commissioner Policy, Procedures and Training Lisa C. Fitzpatrick, Assistant Deputy Commissioner
FAMILY INDEPENDENCE ADMINISTRATION James K. Whelan, Executive Deputy Commissioner
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FAMILY INDEPENDENCE ADMINISTRATION Seth W. Diamond, Executive Deputy Commissioner
FAMILY INDEPENDENCE ADMINISTRATION Seth W. Diamond, Executive Deputy Commissioner James K. Whelan, Deputy Commissioner Policy, Procedures and Training Lisa C. Fitzpatrick, Assistant Deputy Commissioner
FAMILY INDEPENDENCE ADMINISTRATION Matthew Brune, Executive Deputy Commissioner
FAMILY INDEPENDENCE ADMINISTRATION Matthew Brune, Executive Deputy Commissioner James K. Whelan, Deputy Commissioner Policy, Procedures, and Training Stephen Fisher, Assistant Deputy Commissioner Office
FAMILY INDEPENDENCE ADMINISTRATION Seth W. Diamond, Executive Deputy Commissioner
FAMILY INDEPENDENCE ADMINISTRATION Seth W. Diamond, Executive Deputy Commissioner James K. Whelan, Deputy Commissioner Policy, Procedures, and Training Lisa C. Fitzpatrick, Assistant Deputy Commissioner
FAMILY INDEPENDENCE ADMINISTRATION Seth W. Diamond, Executive Deputy Commissioner
FAMILY INDEPENDENCE ADMINISTRATION Seth W. Diamond, Executive Deputy Commissioner James K. Whelan, Deputy Commissioner Policy, Procedures, and Training Lisa C. Fitzpatrick, Assistant Deputy Commissioner
FAMILY INDEPENDENCE ADMINISTRATION Matthew Brune, Executive Deputy Commissioner
FAMILY INDEPENDENCE ADMINISTRATION Matthew Brune, Executive Deputy Commissioner James K. Whelan, Deputy Commissioner Policy, Procedures, and Training Stephen Fisher, Assistant Deputy Commissioner Office
FAMILY INDEPENDENCE ADMINISTRATION Seth W. Diamond, Executive Deputy Commissioner
FAMILY INDEPENDENCE ADMINISTRATION Seth W. Diamond, Executive Deputy Commissioner James K. Whelan, Deputy Commissioner Policy, Procedures, and Training Lisa C. Fitzpatrick, Assistant Deputy Commissioner
FAMILY INDEPENDENCE ADMINISTRATION Seth W. Diamond, Executive Deputy Commissioner
FAMILY INDEPENDENCE ADMINISTRATION Seth W. Diamond, Executive Deputy Commissioner James K. Whelan, Deputy Commissioner Policy, Procedures and Training Lisa C. Fitzpatrick, Assistant Deputy Commissioner
FAMILY INDEPENDENCE ADMINISTRATION Seth W. Diamond, Executive Deputy Commissioner
FAMILY INDEPENDENCE ADMINISTRATION Seth W. Diamond, Executive Deputy Commissioner James K. Whelan, Deputy Commissioner Policy, Procedures and Training Lisa C. Fitzpatrick, Assistant Deputy Commissioner
FAMILY INDEPENDENCE ADMINISTRATION Seth W. Diamond, Executive Deputy Commissioner
FAMILY INDEPENDENCE ADMINISTRATION Seth W. Diamond, Executive Deputy Commissioner James K. Whelan, Deputy Commissioner Policy, Procedures and Training Lisa C. Fitzpatrick, Assistant Deputy Commissioner
FAMILY INDEPENDENCE ADMINISTRATION Seth W. Diamond, Executive Deputy Commissioner
FAMILY INDEPENDENCE ADMINISTRATION Seth W. Diamond, Executive Deputy Commissioner James K. Whelan, Deputy Commissioner Policy, Procedures and Training Lisa C. Fitzpatrick, Assistant Deputy Commissioner
FAMILY INDEPENDENCE ADMINISTRATION Seth W. Diamond, Executive Deputy Commissioner
FAMILY INDEPENDENCE ADMINISTRATION Seth W. Diamond, Executive Deputy Commissioner James K. Whelan, Deputy Commissioner Policy, Procedures, and Training Lisa C. Fitzpatrick, Assistant Deputy Commissioner
FAMILY INDEPENDENCE ADMINISTRATION Seth W. Diamond, Executive Deputy Commissioner
FAMILY INDEPENDENCE ADMINISTRATION Seth W. Diamond, Executive Deputy Commissioner James K. Whelan, Deputy Commissioner Policy, Procedures, and Training Lisa C. Fitzpatrick, Assistant Deputy Commissioner
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FAMILY INDEPENDENCE ADMINISTRATION Matthew Brune, Executive Deputy Commissioner James K. Whelan, Deputy Commissioner Policy, Procedures, and Training Stephen Fisher, Assistant Deputy Commissioner Office
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FAMILY INDEPENDENCE ADMINISTRATION Seth W. Diamond, Executive Deputy Commissioner
FAMILY INDEPENDENCE ADMINISTRATION Seth W. Diamond, Executive Deputy Commissioner James K. Whelan, Deputy Commissioner Policy, Procedures, and Training Lisa C. Fitzpatrick, Assistant Deputy Commissioner
FAMILY INDEPENDENCE ADMINISTRATION Seth W. Diamond, Executive Deputy Commissioner
FAMILY INDEPENDENCE ADMINISTRATION Seth W. Diamond, Executive Deputy Commissioner James K. Whelan, Deputy Commissioner Policy, Procedures, and Training Lisa C. Fitzpatrick, Assistant Deputy Commissioner
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FAMILY INDEPENDENCE ADMINISTRATION Seth W. Diamond, Executive Deputy Commissioner
FAMILY INDEPENDENCE ADMINISTRATION Seth W. Diamond, Executive Deputy Commissioner James K. Whelan, Deputy Commissioner Policy, Procedures and Training Lisa C. Fitzpatrick, Assistant Deputy Commissioner
FAMILY INDEPENDENCE ADMINISTRATION Matthew Brune, Executive Deputy Commissioner
FAMILY INDEPENDENCE ADMINISTRATION Matthew Brune, Executive Deputy Commissioner James K. Whelan, Deputy Commissioner Policy, Procedures, and Training Lisa C. Fitzpatrick, Assistant Deputy Commissioner
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FAMILY INDEPENDENCE ADMINISTRATION Seth W. Diamond, Executive Deputy Commissioner
FAMILY INDEPENDENCE ADMINISTRATION Seth W. Diamond, Executive Deputy Commissioner James K. Whelan, Deputy Commissioner Policy, Procedures, and Training Lisa C. Fitzpatrick, Assistant Deputy Commissioner
FAMILY INDEPENDENCE ADMINISTRATION Matthew Brune, Executive Deputy Commissioner
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FAMILY INDEPENDENCE ADMINISTRATION Seth W. Diamond, Executive Deputy Commissioner
FAMILY INDEPENDENCE ADMINISTRATION Seth W. Diamond, Executive Deputy Commissioner James K. Whelan, Deputy Commissioner Policy, Procedures and Training Lisa C. Fitzpatrick, Assistant Deputy Commissioner
FAMILY INDEPENDENCE ADMINISTRATION Seth W. Diamond, Executive Deputy Commissioner
FAMILY INDEPENDENCE ADMINISTRATION Seth W. Diamond, Executive Deputy Commissioner James K. Whelan, Deputy Commissioner Policy, Procedures, and Training Lisa C. Fitzpatrick, Assistant Deputy Commissioner
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