Forms | Choices You

Forms & Policy

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COVID-19 Related Forms

Release of Information ( For Annual Packet, Fillable-Online)

Release of Information (For Annual Packet, PDF)

Release of Information for Specific Item Only (Fillable-Online)

Seizure Record (PDF)

Seizure Record Chart (PDF)

Self-Med Assessment Packet (PDF)

Severe Weather Drill (PDF)

Shared Food Receipts Tracking - Food Stamp Form (PDF)

Skills Assessment (PDF)

Staff Area Consent (PDF)

Statement of Understanding (PDF)

Test or Procedure Record (PDF)

UI/MUI Report (PDF)

Unanticipated Hospitalization MUI Form (PDF)

Weather Safety Inservice (PDF)

Yearly Weight Record (PDF)

Administrative Forms

Admission Transfer Discharge Checklist (PDF)

Bar Code Sheet - Health Related Activities (PDF)

Bar Code Sheet - Staff (PDF)

Blank Cash Ledger (Excel)

Calendar (PDF)

Cash Ledger (PDF)

Chard Snyder FSA Reimbursement Form (PDF)

Client Binder (PDF)

Client Budget Forms (PDF)

Compliance: Transportation Waiver, No Insurance (Fillable-Online)

Compliance: Transportation Waiver, Non-Driver (Fillable-Online)

Day Hab Bus Checklist (PDF)

Direct Deposit Form (PDF)

Director's Home Review (PDF)

EBT Ledger for Licensed Homes (PDF)

EBT Tracking Template (Excel File)

Educational Allowance Reimbursement (PDF)

Employee Personal Information Change (PDF)

Expense Reimbursement Form (PDF)

Finance Sheet (PDF)

Finder's Fee Request (PDF)

First Report of Injury, Occupational Disease or Death (PDF)

Follow-Up Med Error In-Service Form (PDF)

Food Stamp Chart (PDF)

Form Summary Report (PDF)

FSA Claim Reimbursement Form (PDF)

Health & Welfare Alerts (PDF)

In-Home Meal Count for Staff (PDF)

Incidental Expenses (PDF)

Individual Specific Training (for Client) (PDF)

Inservice Attendance Verification (PDF)

Inservice Request Form (PDF)

ISP Tally Sheet (PDF)

ISP Training Signature Sheet (PDF)

Job Posting Request (PDF)

Master Signature Log (PDF)

Med Class Application (PDF)

Med Admin Skills Checklist (PDF)

Mileage Log - Updated 05/24 (PDF)

New Employee Orientation Receipt (PDF)

New Manager Training Sheet With OBO (PDF)

Program/Person Specific Training (PDF)

Phone Call Documentation (PDF)

Planned Hour Donation Form (PDF)

Power of Attorney (PDF)

Receipts (PDF)

Request for Paid Time Off (PDF)

Residential Respite (PDF)

Residential Specialist Short-Term Training (PDF)

Schedule For the Week (PDF)

Search Procedures & Checklist (PDF)

Shared Food Receipts Tracking - Non-Licensed Only (PDF)

Staff Activity Cost Summary (PDF)

Staff Exchange of Information (PDF)

Staff Schedules (PDF)

Time Sheet (PDF)

Transportation Checklist (PDF)

Transportation Template (Excel)

Van Checklist (PDF)

Vehicle Accident Reporting (PDF)

Vehicle Mileage Sheet (PDF)

Verbal Warning (PDF)

Volunteer Application (PDF)

Written Corrective Action (PDF)

Home Forms

13-D Sprinkler & Alarm Inspection Report (PDF)

Annual Maintenance Checklist (PDF)

Bed Bug Fact Sheet (PDF)

Bed Bug Strategy Guide (PDF)

Laundry Load Guide (PDF)

OSHA Checklist (PDF)

Program Policies & Procedures

Personnel Policies & Procedures

COVID-19 Policy 5-4-20

Full Personnel Policy Listing

Personnel Policies Table of Contents

Policy 1: Purpose of Personnel Policies and Procedures

Policy 2-A: Equal Employment Opportunity - Fair Employment Practices

Policy 2-B: Equal Opportunity - Sexual Harassment

Policy 2-C: Equal Opportunity - Immigration and Control Act

Policy 2-D: Equal Opportunity - Resolving Employment and Program Participant Discrimination Complaints

Policy 3: Employee Selection & Hiring Procedures

Policy 4: Employee Classifications

Policy 5: Employment Relations Policy Statement

Policy 6: Wage and Salary Administration

Policy 7: Attendance & Punctuality

Policy 8: Agency Vehicle Driving Standards

Policy 8 Addendum: Personal Mileage Reimbursement Policy

Policy 9: Protocol - Telephone/Smoking/Personnel Records

Policy 10: Drugs & Alcohol

Policy 11: Other Employment

Policy 12: Conflict of Interest

Policy 13: Standards of Conduct - Performance Improvement Process

Policy 13-A: Standards of Conduct - Breaches of Employee Obligations (Trust)

Policy 14: Open Door Resolution of Issues, Complaints or Suggestions

Policy 15: Insured Employee Benefits

Policy 16: Unplanned Paid Leave

Policy 17: Leaves of Absence

Policy 18: Bereavement

Policy 18-A: Civic Duty

Policy 19: Vacation

Policy 20: Holidays

Policy 21: Training & Development

Policy 21-A: Tuition Reimbursement

Policy 22: Exiting Employees

Policy 23: Weekly Disability Income

Policy 24: Telephone Use

Policy 25: Fraternization

Policy 27: Safety

Policy 28: Information Systems

Policy 29: Requests for Employee References

Policy 30: Gift Giving

Policy 31: Workplace Violence

Policy 32: "No Weapons"

Policy 33: Pager Delegation

Policy 34: Transfer Policy

Policy 35: Standards of Grooming & Dress

Policy 37: Statements to the News Media

Policy 38: Management Structure and Authority

Policy 39: Search Policy

Policy 40: Employee Meals/Reimbursement

Fiscal Policies

Policy 1: Safe Keeping of Client Funds

Policy 2: Client Bank Account

Policy 3: Petty Cash Fund Program Cash Accounts

Policy 4: Overdraft Charges and Lost Funds Reimbursement

Policy 5: Client Bank Account Reconciliation

Policy 6: Accounts Payable

Policy 7: Purchasing Policy

Policy 8: Credit Card Policy

Policy 11: Choices Wish List

CICL Client Intake/Modification/Exit Policies & Procedures