REPORT OF CHANGE CANO TEMPLATE

AND REPORT OF CHANGE GUIDE

SUBJECT

ELEMENTS

• Enter: "ROC, type of change and action"
  
  For example:
  ROC – Job Ended – Case Pended
  
• If multiple changes are reported, caseworkers have the option of using acronyms
  
  For example:
  ROC – ADDR/EAIN/DEMH – Benefits Changed

• Document the date the report was received, how it was received, and who reported the change.

• Document change reported.
  
  Note: Refer to "Change Report Guide" for pertinent information to ask when accepting reports of change by phone or face-to-face.
  
• State if report change was routed to another worker (ET, WDS, case manager, service provider) or agency
  
• Document action taken based on report of change.
  
• It is highly recommended and preferred to document notices that were sent, but it is not required.

CHANGE REPORTED

QUESTIONS TO ASK / INFORMATION NEEDED

If the household member started a job, document the following information:

• Employer's/supervisor's name and telephone number
• Start date of employment
• Expected hours of work per month or work schedule
• Full-time or part-time
• Hourly pay rate
• Pay period
• Verification used; if collateral contact was used, list the name and telephone number

If the household member ended their job:

• Employer's/supervisor's name and telephone number
• Date of job ending
• Reason for job ending
• Date and amount of last pay received including YTD gross
• Verification used; if collateral contact was used, list the name and telephone number

If the household member changed employment status from full-time to part-time:

• Effective date of change
• Hours of work and schedule
• Hourly pay rate
• Full-time or part-time
• Verification used; if collateral contact was used, list the name and telephone number

Change in self-employment

• Effective date of change
• Type of self-employment
• Period of self-employment
• Monthly gross earnings
• Seasonal or annual
• Income and expenses allowed (50% versus actuals)
• Verification used; if collateral contact was used, list the name and telephone number

• New address
• Household composition ***
• Date of move
• Monthly rent amount / mortgage payment / subsidized housing
• SUD / Anticipated utility payments ***
• Type of verification ***

• Name of the person who moved in or out of the home
• Date the person moved in or out
• Relationship of the PI to the person
• Social security number
• Date of birth
• Income
• Resource
• Purchase and prepare (for SNAP)
• Verification used; if collateral contact was used, list the name and telephone number
• Apply appropriate program rules for other information needed.

• Name of bank or institution
• Account number
• Source of money deposited in the bank or cash on hand
• Verification used; if collateral contact was used, list the name and telephone number

• Make, model, year of vehicle
• Value of vehicle
• Amount owed
• How is the vehicle used? (i.e., family/basic transportation, going to work, etc.)
• Verification used; if collateral contact was used, list the name and telephone number

• Source of income
• Amount of income
• Effective date of change
• How long is the change anticipated to last
• Verification used; if collateral contact was used, list the name and telephone number

• New amount
• Effective Date of Change
• Verification used; if collateral contact was used, list the name and telephone number

• Primary holder
• Insurance company's name, address, and telephone number
• Effective date of coverage for each person covered
• Name of household members covered
• Extent of coverage (i.e. medical, dental, vision, accidental only, etc.)
• Group and policy number
• Verification used; if collateral contact was used, list the name and telephone number

Next Section

2012-01 (05/12)