SFN 11, Emergency Assistance Action Plan 415-65-25

(Revised 10/02 ML #2812)

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(Appendix G)

 

The "Emergency Assistance Action Plan" is a form which may be used to assist the emergency assistance applicant and county LIHEAP eligibility worker to address problems that contributed to an energy crisis. It is designed to be used in combination with financial assistance from the Emergency Assistance Program of either LIHEAP or Energy Share of North Dakota with those applicants who are capable of making changes to improve their economic situation.

 

The first section explains the purpose of the Emergency Assistance Program. Space is provided for the worker to explain what emergency assistance has been approved.

 

The worker is to CIRCLE either "LIHEAP" or "Energy Share" to indicate which agency is completing the form.

 

Problem Statement

This section should be used to identify problems the worker and customer agree have contributed to the crisis. Examples might be lack of education/training for a higher paying job, lack of transportation for job search, problems with developing and following a budget, shelter costs are too high for income available, etc.

 

Action Plan

This section is used to identify possible referrals or other actions the customer can take to begin resolving the problems identified. For example, someone whose shelter costs are too high might be referred for weatherization services or to Low Income Housing. Use the "Comments" block to explain any details about the Action Plan. For example, the plan might include an application for Low Income Housing, but if there is a long waiting list, a referral to weatherization services can be made for the current residence as well as a referral to the energy supplier to negotiate a year around monthly payment plan. The worker can write in the phone numbers and/or addresses of the referred agencies or the appointment dates if the worker helps set up the first appointment.

 

The Action Plan will be most effective for the cooperative customer who wants to make improvements. However, it may also be used with the more reluctant customer who may not have given much thought to the reasons for his repeated crises.

 

When a customer is uncooperative or has few skills, it is especially important to set small goals. If he/she is overwhelmed by too much at once, he/she is more likely to do nothing.

 

The "Action Plan" cannot be used as a referral form, because it may contain more information than the referred agency needs, especially if multiple problems are identified. The actual referrals to agencies identified in the Action Plan should be made by separate letters. The Release of Information may be completed by the worker by filling in the agency name (CIRCLE either Energy Share or County Social Services, as appropriate) and the customer name.

 

Signature

The customer and worker both sign and date the "Action Plan."

 

Distribution

The customer receives the original copy and the yellow copy goes to the agency case file.

 

This form is available through the Department of Human Services and may also be obtained electronically via E-Forms. (69kb pdf)