Form Rs 3a - Client Tracking
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1STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
DATE:
CASE NUMBER:
CLIENT TRACKING
TYPE OF AID:
CLIENT'S NAME:
1) RCA
4) SSI/SSP
TO:
ALIEN NUMBER:
2) CalWORKs
5) Non-Cash
PHONE NUMBER:
3) GR/GA
SOCIAL SECURITY NUMBER:
FROM:
Reason for Communicating Information (Check
and/or complete applicable item)
REFERRAL AGENCY/CWD/SERVICE PROVIDER USE ONLY
Client is being referred to_________________________________________ Service(s) to be provided by:
(COMPONENT)
________________________________ at _______________________________________________ , (
) _______________ .
(PROVIDER)
(ADDRESS)
(PHONE NUMBER)
Client must report by _________________________________ .
Comments: ___________________________________________
(DATE)
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
SERVICE PROVIDER USE ONLY
Client reported on _______________________________________ as directed and has been entered in service. Anticipated date of
(DATE)
completion _____________________________________________.
Client reported on _______________________________________as directed is on waiting list. Anticipated date of enrollment in ___
(DATE)
service ________________________________________________.
Client has not participated or cooperated in training program because he/she failed to ______________________________________
__________________________________________________________________________________________________________.
Client has not accepted offer of employment.
JOB OFFER:
DATE OF OFFER:
STARTING WAGE:
EMPLOYER'S NAME:
EMPLOYER’S ADDRESS:
TELEPHONE NUMBER:
(
)
Job Entry __________
30 Day __________
90-day Follow-up________
New Job____________
Change in Employment Status_______________
DATE
DATE
DATE
DATE
DATE
EMPLOYER'S NAME
ADDRESS:
$
POSITION:
DATE STARTED:
TELEPHONE NUMBER:
CONTACT PERSON:
RATE OF PAY:
HOURS PER DAY:
HOURS PER WEEK
Permanent Part Time
Permanent Full Time
Seasonal Until: ____________
Working - Original Job
Working - New Job
Not Working
Case is Active
Quit job as of (Date) _____________________________________
Received Raise
Fired as of: (Date) ____________
DATE COMPLETED
DATE CASE CLOSED
Completed Participation
Case Closed
Other: ________________
COMMENTS:
NAME:
TITLE:
AUTHORIZED SIGNATURE:
DATE:
NAME OF AGENCY:
PHONE NUMBER:
(
)
RS 3A (5/03)
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