SR 03-36 Dated 08/03

STATE OF NEW HAMPSHIRE

INTER-DEPARTMENT COMMUNICATION

 

SIGNATURE DATE:

July 18, 2003

FROM:

OFFICE OF THE DIRECTOR Mary Anne Broshek

AT (OFFICE):

Division of Family Assistance

TO:

DFA Supervisors

Managers of Administration

Program Managers

 

SUBJECT:

Release of New Spanish and Bosnian Language Versions of Form 770, Reimbursement Agreement and Acknowledgement

EFFECTIVE DATE:

August 1, 2003

 

 

SUMMARY

 

This SR releases the Spanish language and Bosnian language versions of Form 770, Reimbursement Agreement and Acknowledgement.

 

BACKGROUND

 

Title VI of the Civil Rights Act of 1964 prohibits agencies in receipt of federal financial assistance from denying persons with limited English proficiency access to programs on the basis of national origin. As a result of Presidential Executive Order 13166 dated August 11, 2000, the U.S. Department of Health and Human Services issued written policy guidance on August 30, 2000, for health and human services providers to ensure language assistance for individuals with limited English proficiency. In response to the state’s increasing Spanish and Bosnian-speaking population, several DFA forms have been translated. Additional Spanish and Bosnian language versions of other DFA and Departmental forms will follow and will be released by SR under separate cover.

 

POLICY

 

The Spanish and Bosnian language version of Form 770, Reimbursement Agreement and Acknowledgement, is used in the same manner as the English version. Therefore, no form instructions are being released.

 

The Spanish and Bosnian language versions have been formatted in the same manner as the English language version. The SR number and date of the Spanish and Bosnian versions match the SR number and date of the most current English version. Each time the English language version changes, the Spanish and Bosnian language versions will be changed accordingly and released by SR with the revised English version. The Spanish language form is identified by the suffix "(Sp)" immediately after the form number. Similarly, the suffix "(Bo)" immediately after the form number identifies the form as a Bosnian language version.

 

IMPLEMENTATION

 

Once copies of the forms released by this SR are received, District Offices may begin using the foreign language versions whenever the need arises. Reorder by emailing the Policy Development Supervisor via Lotus Notes and specifying the amount needed.

 

CLIENT NOTIFICATION

 

Clients will be provided with the newly released forms on an as needed basis.

 

TRAINING

 

No training is planned or needed.

 

FORMS POSTING INSTRUCTIONS

 

Remove and Destroy

Insert Behind the English Language Version

 

Forms Manual

 

None

 

 

 

None

 

 

Form 770(Bo)

SR 03-06/April, 2003

1 sheet

 

Form 770(Sp)

SR 03-06/April, 2003

1 sheet

 

DISPOSITION

 

This SR may be destroyed or deleted after its contents have been noted, the attached forms posted to the paper Forms Manual, and the SR has been posted to the On-line manual.

 

DISTRIBUTION

 

This SR will be distributed according to the electronic distribution list for Division of Family Assistance policy releases. This SR, and revised On-Line Manuals, will be available for agency staff in the On-Line Manual Library, and for public access on the Internet at http://www.dhhs.state.nh.us/DHHS/DFA/LIBRARY, effective August 1, 2003.

 

This SR will be distributed under separate cover to all hard copy holders of the Forms Manual.

 

DFA/JBV:s