Case Name:	Case DCN/User ID:	Contractor:	Staff Name/ID:
Reviewed By:	Review Date/Type: ☐ Monitoring ☐ Targeted ☐ Other	Participant Status: ☐ ABAWD ☐ Volunteer	Review Period:
SNAP Application & Activities N/A SNAP application enrolled correctly (participation type, DCN present, correct provider selected, exited app process followed correctly) N/A Five required SNAP activities present (funding/101/107/205/213) N/A Activities closed correctly N/A Correct activity codes entered N/A Correct funding code(s) N/A Employment added to employment tab N/A Credentials added to credentials section N/A Wagner-Peyser application, if enrolling in WIOA N/A Resume, if enrolled in work activity Notes:
Objective Assessment: N/A Current to the SNAP application and completed prior to entering a training or work activity N/A Career pathway and desired wage noted N/A Services sought are identified N/A Education and/or work history completed N/A All skills and barriers sections completed N/A Additional assessments completed if need was indicated Notes:
Individual Employment Plan: N/A Objectives present for each goal, outline steps to achieve the goal and not the same as the goal N/A Minimum of one short-term and one long-term goal and goals are not the same N/A Goals align with activities on SNAP application N/A Goals/objectives reflect the desired career pathway/wage stated in Objective Assessment N/A Timeframe for completion N/A Assessment/skills/barriers reflected in objectives and/or goals N/A Employment is the final goal N/A Updated with changes Notes:
Case Notes: N/A Mandatory Initial case note entered and contains required information N/A DWD Statewide Service Notes policy followed (see handbook for guidance) N/A Present for any supportive service,with details of justification/need/exploration of other resources N/A Present for any activity or service provided, including actions outside of MoJobs system N/A Entered at time of contact Notes:
Intensive Case Management/Supportive Services: N/A TRE/WRE issuances follow policy (justified, open activity, verified attendance) N/A TRE/WRE issued in accordance with provider policy (timeframes, amounts, etc) N/A Barriers addressed and/or referred to Community Based Organizations N/A Job Retention Services follow policy (see handbook for guidance) Notes:
Documentation – Required Forms N/A FS-5 (DWD-PO-608) in case file and/or submitted for gained employment or ABAWD use N/A Eligibility & DCN verification form if SNAP application was created by staff in MoJobs N/A Complies with confidentiality requirements (file contains information for this participant only) ABAWD only: N/A Exclusions Checklist present or discussion case noted N/A Job Center WIOA Services form (DWD-PO-609) for regaining eligibility N/A Agreement to Volunteer completed and submitted to FSD N/A Job description form for WE activity N/A Job Search Contract (DWD-PO-604A) and logs (DWD-PO-604B) for self-directed job search N/A Verification of hours submitted to FSD within 48 hours Notes:
Reviewer Comments/Recommendations: