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Appendix XIII: Entering Information on the Guardianship Referral Form

APS IH / May 2011

Procedures for Documenting the APS Guardianship Referral Form

The APS guardianship referral form is designed to pre-fill with some information that is located in IMPACT, while other information must be entered manually by the specialist. The information entered on the referral form falls into three categories:

  •   information required to generate the referral form;

  •   information pulled from IMPACT into the referral form; and

  •   information entered by the APS specialist on the referral form.

Information Required in IMPACT to Generate APS Guardianship Referral Form

If certain information is not entered into the IMPACT case management system before attempting to generate the referral form, the form will fail to generate. The following information must be entered in IMPACT before the referral form will generate:

  •   Client’s name

  •   Client’s address or current location, if different. When a client has been moved to a facility, the specialist goes to the Person Detail page and:

  •   clicks on the Address Detail,

  •   clicks the Add button,

  •   selects Fac Res for the type,

  •   enters the name of the facility in the Attn box, and

  •   enters the address of the facility and clicks Save.

  •   Client’s citizenship (Person Characteristics section)

  •   Client’s race

  •   Client’s sex

  •   Client’s ethnicity


  •   At least one valid fining of abuse, neglect or exploitation

Information Pulled From IMPACT to the APS Guardianship Referral Form

Certain fields in the referral form are pre-filled with information already available in IMPACT. While the referral form will generate without this information, these fields will remain blank and cannot be edited if the necessary information is not entered in IMPACT before completing the form. This information includes the client's:

  •   date of birth;

  •   Social Security number;

  •   driver’s license number;

  •   Medicaid or Medicare number;

  •   marital status;

  •   facility name, if applicable;

  •   phone number;

  •   family members’ names, location and contact information;

  •   friends’ names, locations and contact information;

  •   medical and other professional collaterals’ names, locations and contact information; and

  •   income, property, and other resources discovered during the course of the investigation (Income and Resources section of the Person Detail page).

During an emergency referral to DADS Guardianship Services, the specialist is not required to enter all known persons on the referral form. Any information not entered into the original DADS guardianship referral form is entered in IMPACT and provided to DADS as a hard copy within five days of the referral.

Information Entered Manually on the APS Guardianship Referral Form

Certain fields on the referral form cannot be populated with information from IMPACT. Some of these fields are required at the time the initial referral form is submitted to DADS and are marked below as mandatory. The APS specialist must manually enter the following information:

Section I. DFPS Employee Information:

  •   Specialist’s cell phone number (mandatory)

  •   Supervisor’s cell phone number (mandatory)

Section II. Proposed Ward Information

  •   Verification of the client’s current location by checking the appropriate boxes on the form (mandatory)

  •   GOLD address type (mandatory)

  •   Contact name and phone number at client’s current location, if appropriate (mandatory)

  •   If the client appears to be indigent

  •   Description of any safety concerns that DADS staff may need to be aware of, if known at the time of referral (mandatory)

Section III. Emergency Order for Protective Services (EOPS)

  •   If an EOPS was obtained (mandatory for emergency referrals)

  •   Date of the removal (mandatory for emergency referrals)

  •   Date the order expires (mandatory for emergency referrals)

Section V. Reason for Referral

  •   Responses to questions 1-10 (mandatory)

  •   Least restrictive alternative information (mandatory)

Section VI. Physicians and Other Professional Collaterals

  •   Last time client saw physician or other professional before DFPS intervention

  •   What prompted physician or professional to come into contact with client

  •   Whether a written was evaluation provided

Section VII. Family

  •   Does a family member have the client’s power of attorney (POA)?

  •   Has APS asked the family member to serve as guardian?

Section VIII. Assets and Resources

      All information in this section obtained during the investigation that was not entered on the Person Detail page is entered by the specialist

Section IX. Property

      All information in this section obtained during the investigation that was not entered on the Person Detail page is entered by the specialist

Section X. Pending Information

      The specialist checks either DFPS or DADS to indicate which department is responsible for obtaining and providing the listed information. If information indicated is not applicable to the current investigation (for example, an EOPS was not performed) then both check boxes are left blank (mandatory).

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