SR 11-46 Dated 12/11

STATE OF NEW HAMPSHIRE

INTER-DEPARTMENT COMMUNICATION

 

DFA SIGNATURE DATE:

November 28, 2011

FROM:

OFFICE OF THE DIRECTOR, DFA Terry R. Smith

AT (OFFICE):

Division of Family Assistance

TO:

DFA Supervisors

NHEP teams

District Office Managers of Operations

 

SUBJECT:

Release of the Following Revised Bosnian and Spanish Language Versions of DFA Forms: DFA 77R(Bo) and DFA Form 77R(Sp), Emergency Assistance for Housing: What You Need to Know, DFA Form 243(Bo) and DFA Form 243(Sp), Maybe There is Help! The Family Violence Option (FVO); DFA Form 752A(Bo) and DFA Form 752A(Sp), Authorization for Release of Protected Health Information for the Use and Disclosure of Individually Identifiable Health Information, DFA Form 773(Bo) and DFA Form 773(Sp), Certification of Continued Absence, DFA Form 808(Bo) and DFA Form 808(Sp), Proof Needed to Determine Your Assistance, DFA Form 810(Bo) and DFA Form 810(Sp), Notice of Rights and Responsibilities, and DFA Form 811S(Bo) and DFA Form 811S(Sp), Application: Statements of Understanding

EFFECTIVE DATE:

December 30, 2011

 

 

SUMMARY

 

This SR releases the Bosnian and Spanish language versions of the following forms to align with recent updates to the corresponding English versions:

 

·   DFA Form 77R(Bo) and DFA Form 77R(Sp), Emergency Assistance for Housing: What You Need to Know;

·   DFA Form 243(Bo) and DFA Form 243(Sp), Maybe There is Help! The Family Violence Option (FVO);

·   DFA Form 752A(Bo) and DFA Form 752A(Sp), Authorization for Release of Protected Health Information for the Use and Disclosure of Individually Identifiable Health Information;

·   DFA Form 773(Bo) and DFA Form 773(Sp), Certification of Continued Absence;

·   DFA Form 808(Bo) and DFA Form 808(Sp), Proof Needed to Determine Your Assistance;

·   DFA Form 810(Bo) and DFA Form 810(Sp), Notice of Rights and Responsibilities; and

·   DFA Form 811S(Bo) and DFA Form 811S(Sp), Application: Statements of Understanding.

 

The Bosnian language forms are identified by the suffix "(Bo)" immediately following the form number and the Spanish language forms are identified by the suffix "(Sp)’ immediately following the form number.

 

POLICY

 

The Bosnian and Spanish versions of the forms released in this SR are now aligned with recent updates to the corresponding English versions of these forms. Therefore, the SR number and date of the translated forms released in this SR will match the English versions of the forms. Because the Bosnian and Spanish language versions of the forms released in this SR are used in the same manner as the English versions, no form instructions are being re-released.

 

All supplies of the old versions of these forms in the District Offices may be recycled upon receipt of the new versions.

 

IMPLEMENTATION

 

An initial supply of each of the translated forms released in this SR has been sent to each District Office as follows:

 

§   25 of each individual form to the Claremont, Concord, Keene, Laconia, Manchester, Southern, Seacoast, and Rochester District Offices; and

§   10 copies of each individual form to the Berlin, Central Healthy Kids, Conway, and Littleton, District Offices.

 

Once copies of the newly translated forms released by this SR are received, District Offices may begin using the foreign language versions whenever the need arises. Reorder by contacting the Supervisor of the DFA Policy Development Unit and specifying the amount needed.

 

All supplies of the old versions of these forms in the District Offices may be recycled upon receipt of the new versions.

 

CLIENT NOTIFICATION

 

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

 

TRAINING

 

No special training is planned or needed.

 

FORMS MANUAL POSTING INSTRUCTIONS

 

Remove and Destroy

Insert

 

Forms Manual

 

 

 

None

DFA Form 77R(Bo), Emergency Assistance for Housing: What You Need to Know,

DFA SR 08-29/October, 2008 Rev. 8/11

1 back-to-back sheet

DFA Form 77R(Sp), Emergency Assistance for Housing: What You Need to Know,

DFA SR 02-13/July, 2002, Rev 8/11

1 back-to-back sheet

DFA Form 77R(Sp), Emergency Assistance for Housing: What You Need to Know,

DFA SR 08-29/ October, 2008 Rev. 8/11

1 back-to-back sheet

None

DFA Form 243(Bo), Maybe There is Help! The Family Violence Option (FVO),

DFA SR 09-04/August, 2009

1 back-to-back sheet

DFA Form 243(Sp), Maybe There is Help! The Family Violence Option (FVO),

SR 00-08/February, 2000

1 back-to-back sheet

DFA Form 243(Sp), Maybe There is Help! The Family Violence Option (FVO),

DFA SR 09-04/August, 2009

1 back-to-back sheet

None

DFA Form 752A(Bo), Authorization for Release of Protected Health Information for the Use and Disclosure of Individually Identifiable Health Information,

DFA SR 10-40/December, 2010

1 back-to-back sheet

DFA Form 752A(Sp), Authorization for Release of Protected Health Information for the Use and Disclosure of Individually Identifiable Health Information,

DFA SR 08-04/April, 2008 Rev. 8/11

1 back-to-back sheet

DFA Form 752A(Sp), Authorization for Release of Protected Health Information for the Use and Disclosure of Individually Identifiable Health Information,

DFA SR 10-40/December, 2010

1 back-to-back sheet

None

DFA Form 773(Bo), Certification of Continued Absence, DFA SR 10-05/February, 2010

1 single-sided sheet

DFA Form 773(Sp), Certification of Continued Absence, DFA SR 93-74/December, 1993

1 single-sided sheet

DFA Form 773(Sp), Certification of Continued Absence, DFA SR 10-05/February, 2010

1 single-sided sheet

None

DFA Form 808(Bo), Proof Needed to Determine Your Assistance,

DFA SR 09-11/November, 2009 Rev. 6/11

1 back-to-back sheet

DFA Form 808(Sp), Proof Needed to Determine Your Assistance,

DFA SR 02-17/July, 2002

1 back-to-back sheet

DFA Form 808(Sp), Proof Needed to Determine Your Assistance,

DFA SR 09-11/November, 2009 Rev. 6/11

1 back-to-back sheet

None

DFA Form 810(Bo), Notice of Rights and Responsibilities,

DFA SR 08-04/April, 2008

1 back-to-back sheet

DFA Form 810(Sp), Notice of Rights and Responsibilities,

DFA SR 01-38/December, 2001

1 back-to-back sheet

DFA Form 810(Sp), Notice of Rights and Responsibilities,

DFA SR 08-04/April, 2008

1 back-to-back sheet

DFA Form 811S(Bo), Application: Statements of Understanding,

DFA SR 09-33/September, 2009

1 back-to-back sheet

DFA Form 811S(Bo), Application: Statements of Understanding,

DFA SR 11-28/July, 2011

1 back-to-back sheet

DFA Form 811S(Sp), Application: Statements of Understanding,

DFA SR 09-33/September, 2009

1 back-to-back sheet

DFA Form 811S(Sp), Application: Statements of Understanding,

DFA SR 11-28/July, 2011

1 back-to-back sheet

 

DISPOSITION

 

This SR may be destroyed or deleted after its contents have been noted and the this SR has been posted to the On-line manuals.

 

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 www.dhhs.nh.gov/DFA/publications.htm, effective January 30, 2012. Additionally, this SR, and printed pages with posting instructions, will be distributed under separate cover to all internal hard copy holders of the Forms Manual.

 

DFA/JBV:s

 

CERTIFICATE OF DESTRUCTION

I certify that the following copies of the Spanish and Bosnian version forms have been destroyed:

·   Form 77R(Sp), dated 7/02 or 7/02 rev 8/11, SR 02-13;

·   Form 243(Sp), dated 2/00, SR 00-08;

·   Form 752A(Sp), dated 04/08 or 04/08 rev 8/11, SR 08-04;

·   Form 773(Sp), dated 12/93, SR 93-74;

·   Form 808(Sp), dated 7/02, SR 02-17;

·   Form 810(Sp), dated 12/01, SR 01-38; and

·   Form 811S(Bo) & (Sp), dated 9/09, SR 09-33.

District Office Manager of Operations:

 

District Office:

 

 

 

Return this certificate to the DFA Policy Unit, 129 Pleasant St, Brown Bldg, 3rd Floor, Concord, NH 03301, after the instructions in the SR have been carried out.