The Sample Coordinator will make every effort to obtain your response within 15 minutes of the sampled moment. If you (the SSR) are on leave, the Sample Coordinator will so indicate. If you are unavailable because you are on travel, attending a meeting or at training the Sample Coordinator will leave a copy of the form for you to complete. Open returning to the employees official work station, he/she will complete the form noting what he/she was doing at the moment noted on the Observation Form. Once you finish filling in the form, it should be signed and promptly returned to the Sample Coordinator.
you are working on at the selected moment in accordance with the definitions provided later in this document. A case number must be reported whenever a "program" is identified. If a case number is not available (as with some of the job related programs) and the activity involves a specific client, then the clients social security number should be provided in Section I and the clients name in Section III.
100 Medicaid: This program provides medical assistance to low-income
individuals under 21, families with dependent children, individuals and couples who are age 65 or older and blind or disabled individuals. Related activities include conducting a Medical eligibility determination in accordance with the pre-TANF AFDC standards for combined financial and/or food stamp cases even though the client is eligible for other programs, referring all medical assistance cases to the Department of Health and forwards medical
inquires/reports to Medical Review Team. Also includes any activity related to third party liability (XVIII, self-pay, other) collections including the identification and documentation of other sources of Medical payment that may be primary to Medicaid. This also includes activity in support of the "DC Healthy Families" program.
101 Food Stamps: This program provides for the certification of households with low income and resources for Food Stamps in order to increase their food purchasing power. Related activities include time spent in explaining the program, collecting, documenting, verifying/collaborating and inputting into the ACEDS system all related information (names, addresses, income, assets, social security numbers, etc). Also includes effort spent in completing any required forms, referrals, and sanction activity and in responding to questions relating to receipt of food stamps, the amount received, etc. and effort spent in preparing requests for assistance regarding dormant/frozen accounts (EBT).
102 Temporary Assistance for Needy Families (TANF): This program provides temporary financial assistance and other services to eligible TANF clients. Related activities include time spent in explaining the eligibility requirements, determining eligibility for TANF and identifying/documenting income, resources, deprivation, citizenship, SSN, school attendance and inputting information in the ACEDS system.
103 Interim Disability Assistance: This program provides temporary financial assistance to disabled adults who are ineligible for TANF and who have applied for and are awaiting approval of supplemental security income (SSI). Related activities include explaining eligibility requirements, conducting eligibility determinations, obtaining and verifying the necessary information, inputting the data into the ACEDS system, setting up necessary appointments, tracking the progress of the claim, and representing the household throughout
Instructions for the Random Moment Sample – Revised 9/25/10 Page 3
caring for unrelated children whose parent or other relatives are absent from the household. Related activities include explaining the program requirements, conducting eligibility determinations, making referrals to approved vendors, requesting home studies, inputting or retrieving data from ACEDS, and verifying information including death certificates, social security, income etc. Also includes any activity associated with the Burial Program.
105 POWER (Program on Work, Employment, and Responsibility) This program is a District of Columbia program, which allows TANF applicants/recipients whose physical, and/or mental incapacity's interfere with their ability to
participate in countable work activities to be placed in a special district-funded program to assist them in becoming work ready. Related activities include explaining program requirements, obtaining and submitting medical packets to the Medical Review Team, preparing the Social Data form, obtaining and verifying necessary information, inputting data into ACEDS, tracking the medical review process.
106 SAVE: This program (Systemic Alien Verification and Eligibility or “SAVE”) is designed to verify an alien’s status. Related activities include assembling the required information; reviewing all available information; making computer inquiries; generating all required reports and corresponding with the Bureau of Citizenship and Immigration Services (BCIS) formerly Immigration and Naturalization Service (INS), churches, etc.
107 D.C. Healthcare Alliance: This program provides medical assistance to low- income individuals not otherwise eligible for Medicaid. Specifically, the Alliance serves adults ineligible for Medicaid because they are non-qualified aliens or not disabled, pregnant or parenting. This program also serves non- qualified alien children under 21 who are on the waiting list for the Immigrant Children’s program. This program is programmatically similar to the former Medical Charities Program.
108 Any Other Program: This category would include any program not listed above; if this code is selected, the specific program being worked on must be indicated in the space provided. Related activities include explaining program requirements, conducting eligibility determinations, obtaining and verifying information, inputting data into ACEDS, setting up necessary appointments, tracking the progress of the application/recertification.
109 Common to More Than One Program: This category should be used when more than one program is involved in a given situation. Related activities include collecting/verifying all information supporting or required by more than one program (e.g., name, address, social security number, information on
110 Diversion: This program provides support to allow the client to overcome obstacles to employment. This could include funds for uniforms, tools, auto insurance, auto repairs etc. Related activities include explaining TANF program requirements, conducting eligibility determinations, obtaining and verifying information, and time spent inputting data into ACEDS.
Case Number / Unique Identifier: Enter the case number that identifies the case with which you are engaged at the time of the sample moment. In the absence of a case number, use a unique identifier or the client’s name, which can be used to provide audit documentation.