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DHS required forms

The following forms cannot be replaced by a local county, tribal or employment services agency form.
MFIP/DWP Employment Services Weekly Job Search Activity Log (DHS-5784-ENG) (PDF).

Notices:

· Notice of Requirement to Attend Minnesota Family Investment Program (MFIP) Overview (DHS-2929-ENG) (PDF).

· Employment Services Responsibilities, Rights and Consent (DHS-3172-ENG) (PDF).

· MFIP Notice of Intent to Sanction (DHS-3175-ENG) (PDF).

· Notice of Privacy Practices (DHS-3979-ENG) (PDF).

Forms related to assessments and screenings:

· Assessor/Treatment Provider Report (DHS-4316-ENG) (PDF).

· MFIP Self-Screen (DHS-3482) (PDF).

· Brief Screening Tool for Special Learning Needs (DHS-3504-ENG) (PDF).

Forms related to Injury Protection Program Injury Protection Program (IPP) - Injury Protection Program Participant Information and Authorization to Release Medical Information (DHS-3994-ENG) (PDF).

· Injury Protection Program (IPP) - First Report of Injury (DHS-3995-ENG) (PDF).

· Injury Protection Program Participant Medical Referral and Medical Care Provider Information Letter (DHS-3996-ENG) (PDF).

· Injury Protection Program (IPP) - Participant Injury Status Report (DHS-3997-ENG) (PDF).

Forms related to the Employment Plan

· MFIP/DWP Employment Plan – Either the paper version or the electronic employment plan on Workforce One (WF1) is required.

· MFIP/DWP Employment Plan (DHS-4209-ENG) (PDF).

· Employment (DHS-4209A-ENG) (PDF).

· Job Search Requirements (DHS-4209B-ENG) (PDF).

· Unpaid Work Activities (DHS-4209C-ENG) (PDF).

· Education (DHS-4209D-ENG) (PDF).

· Family Safety (DHS-4209E-ENG) (PDF).

· Child Care or Transportation (DHS-4209H-ENG) (PDF).

· Health (DHS-4209I-ENG) (PDF).

· Housing (DHS-4209J-ENG) (PDF).

· Personal/Family Activity (DHS-4209K-ENG) (PDF).

· Legal Issues (DHS-4209L-ENG) (PDF).

· County/State Social Services (DHS-4209M-ENG) (PDF).