FOOD STAMP EMPLOYMENT AND TRAINING PROGRAM
REFERRAL FORM & PARTICIPATION RECORD
Referral Data
County________________________________________________ Date____________________________________________
Registrant’s Name ______________________________________ SSN____________________________________________
Case Head ____________________________________________
Case SSN________________________________________
Address:______________________________________________ Telephone:_______________________________________
______________________________________________ Message: _______________________________________
Food Stamp Certification Period _________________________ to ______________________________
month/year month/year
please print)_____________________________________Name of County Office Worker (
Date Referral Received __________________________________ Date Assessment Scheduled ______________________________
Did registrant appear for assessment? _____YES _____NO If yes, date assessment completed _________________________
If no, date(s) registrant re-contacted? _________________________________ _______________________________
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Component Assignment |
Date Entered |
Date Completed |
Date Ended Without Completion |
Reason |
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Barriers Identified |
Action Taken to End Barrier |
Date |
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Counselor’s Assessment of Participant’s Performance
Outstanding Satisfactory Needs ImprovementAppearance ¨
¨ ¨Attitude ¨
¨ ¨Arrives on time ¨
¨ ¨Completes assignments ¨
¨ ¨Recommendations:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
DCO-205 (rev. 09/02
)INSTRUCTIONS
DCO-205
Use
This is a multi-use form. It is used in the DHS County Office to refer appropriate food stamp program participants to the Food Stamp E&T Program operated by the Department of Workforce Education. (Food Stamp Program participants subject to the Requirement to Work will be referred to the E&T Program in Mississippi, St. Francis, and Union counties.)
The Adult Education Program Office will use the DCO-205 to track E&T Program participation and to prepare the reports required by DHS.
Completion
The DHS county office worker will complete the top part of the form. The Department of Workforce Education will complete the two lower parts of the form.
Retention
DHS will retain a copy of the referral in the case record for three years from the month of origin.
The Adult Education Program Office will retain a copy of the form for three years from the date of the last entry on the form.
Routing
DHS will route the referral to the address shown below:
In Mississippi County Ms. Elizabeth Thompson
Cotton Boll Technical Institute
Adult Education Program
P.O. Box 36
Burdette, AR 72321
In St. Francis County Mr. Walter Meals, III
Crowley’s Ridge Technical Institute
Adult Education Program
P.O. Box 925
Forrest City, AR 72336-0925
In Union County Ms. Patricia Bates
South Arkansas Community College
Adult Education Program
P.O. Box 7010
El Dorado, AR 71731-7010