CAPI Interview /
1. / Date of verbal ERDC request:
Child care benefits start on the first day of the month in which the request is made. However,
the effective date for payment cannot be earlier than the date the provider is in approved listing status with DHS.
2. / Are you homeless? Yes No
(Homeless could mean living in an emergency shelter, shared housing with another family because of job loss or loss of your housing, in a motel, car, park, public place, campsite or other similar place.)
3. / What is your work schedule? For a 2-parent household, approve child care hours only for the parents’ overlapping work hours (authorized student hours may be added).
4. / How many hours a week could you potentially work? If client states they work varied hours, explain when, how and why in TRACS. When entering CC Wrk Hrs on UCMS, allow the maximum verified hours.
5. / Do you have shared custody with any of the children needing care? / Yes / No
6. / Do you need child care for a foster child? / Yes / No
7. / Do you need child care while you are working and attending classes? / Yes / No
(Class hours can only be approved if you are working and attending a school that is eligible for federal financial aid. You must give a copy of your school registration and current class schedule.)
8. / Are children’s immunization records up-to-date? / Yes / No
Parent must agree to meet state immunization guidelines. (FSM Child Care Assistance, Section D) Exemptions can be made for medical or religious reasons.
9. / Does your child need extra care due to a disability? / Yes / No
Code SNR on UCMS if they meet the SNR criteria; DHS 7486 must be completed (FSM Child Care Assistance, Section F)
10. / Name of your child care provider:
Second provider, if any?
11. / Primary provider? (If more than one provider, identify percent of child care for each one).
12. / Is the provider(s) already listed? / Yes / No
Tell clients that DHS will not pay for any child care provided before DHS approves the provider. If they need assistance choosing a provider, tell them to contact their local Child Care Resource & Referral Agency.
**Remember to send out DHS 7294, DHS 7478 and a DHS 7494 and DHS 7492 or a DHS 7494E
if the provider is already listed.***
Page 1 of 2 DHS 0419 (10/16)