NEGATIVE ACTION CASE REVIEW SHEET
Identifiers Reviewer, Date, Type Coding and Documentation DSS-8650 N
Was the Was the
denial / documentation of the
Type of termination reason for the
Action (SR, Date of code entered denial/termination
County Date of Type of Application, Denial or Reason for Denial or Termination entered on on DSS-8590 sufficient to explain Was a DSS-
Case Name Worker FSIS# Case # Reviewer Review Review Change…) Termination. DSS-8590. (TC Used) correct? the action? 8650 issued?
Correct
Incorrect
N/A
Yes
No
N/A
NEGATIVE ACTION CASE REVIEW SHEET
Identifiers Reviewer, Date, Type Coding and Documentation DSS-8650 N
Was the Was the
denial / documentation of the
Type of termination reason for the
Action (SR, Date of code entered denial/termination
County Date of Type of Application, Denial or Reason for Denial or Termination entered on on DSS-8590 sufficient to explain Was a DSS-
Case Name Worker FSIS# Case # Reviewer Review Review Change…) Termination. DSS-8590. (TC Used) correct? the action? 8650 issued?
Yes
No
Categorically Eligible
No
Yes
Immediate
DSS-8650 Notice of Information Needed Notices Earned Income Un
Did the DSS-
8650 request The household
Did the DSS- information that was evaluated Did the worker use
8650 request was If Applicable, Correct base using the correct the correct base
information inappropriate or Was the client Was the client period used or income limit? (net Did worker enter period or
appropriate for unneeded for given the full 10 Was the Notice given 10 income used Income was or gross) (N/A for Earned Income document other
eligibility eligibility days to provide Was a Notice issued working days documented as calculated categorically correctly on the income as
Case Name determination? determination? deductions? Required? correctly? notice? representative? correctly? eligible) DSS-8590? representative?
Correct
Incorrect
N/A
Yes
No
N/A
DSS-8650 Notice of Information Needed Notices Earned Income Un
Did the DSS-
8650 request The household
Did the DSS- information that was evaluated Did the worker use
8650 request was If Applicable, Correct base using the correct the correct base
information inappropriate or Was the client Was the client period used or income limit? (net Did worker enter period or
appropriate for unneeded for given the full 10 Was the Notice given 10 income used Income was or gross) (N/A for Earned Income document other
eligibility eligibility days to provide Was a Notice issued working days documented as calculated categorically correctly on the income as
Case Name determination? determination? deductions? Required? correctly? notice? representative? correctly? eligible) DSS-8590? representative?
Yes
No
Categorically Eligible
No
Yes
Immediate
Unearned Income Deductions Ineligible and Disqualified HH members
Was the
household
evaluated using
the correct income
limit? (net or Did the worker Did the worker Did the worker If yes, did the Did the worker
Did the worker gross) (N/A for enter Earned Did the HH have Did worker calculate the enter all income Are any members worker evaluate code the HH
calculate the categorically Income correctly income deductions request income income deductions deductions on of the HH ineligible the HH member member correctly
Case Name Income correctly? eligible) on the DSS-8590? or exclusions? deductions? correctly? the DSS-8590? or disqualified? correctly? on the DSS-8590?
Correct
Incorrect
N/A
Yes
No
N/A
Unearned Income Deductions Ineligible and Disqualified HH members
Was the
household
evaluated using
the correct income
limit? (net or Did the worker Did the worker Did the worker If yes, did the Did the worker
Did the worker gross) (N/A for enter Earned Did the HH have Did worker calculate the enter all income Are any members worker evaluate code the HH
calculate the categorically Income correctly income deductions request income income deductions deductions on of the HH ineligible the HH member member correctly
Case Name Income correctly? eligible) on the DSS-8590? or exclusions? deductions? correctly? the DSS-8590? or disqualified? correctly? on the DSS-8590?
Yes
No
Categorically Eligible
No
Yes
Immediate
Results Comments and Follow up
Was the
denial / Is any action
termination needed to
Case Name appropriate? correct case? Comments Follow Up
Correct
Incorrect
N/A
Yes
No
N/A
Results Comments and Follow up
Was the
denial / Is any action
termination needed to
Case Name appropriate? correct case? Comments Follow Up
Yes
No
Categorically Eligible
No
Yes
Immediate
ACTIVE ACTION CASE REVIEW SHEET
Identifiers Reviewer, Date, Type Normal vs. Expedited & Timely processing Interview
If interview
Was the was not
Did worker worker's conducted on
Type of process the determination the DOA. Did
Action (SR, cases as of Normal or Did the worker Was an Did worker the worker
County Date of Type of Application, Date of Date Normal or Expedited process the interview conduct an send a DSS-
Case Name Worker FSIS# Case # Reviewer Review Review Change…) Application approved Expedited? correct? case timely? required? interview? 8650?
Correct
Incorrect
N/A
Yes
No
N/A
ACTIVE ACTION CASE REVIEW SHEET
Identifiers Reviewer, Date, Type Normal vs. Expedited & Timely processing Interview
If interview
Was the was not
Did worker worker's conducted on
Type of process the determination the DOA. Did
Action (SR, cases as of Normal or Did the worker Was an Did worker the worker
County Date of Type of Application, Date of Date Normal or Expedited process the interview conduct an send a DSS-
Case Name Worker FSIS# Case # Reviewer Review Review Change…) Application approved Expedited? correct? case timely? required? interview? 8650?
Yes
No
Categorically Eligible
No
Yes
Immediate
Normal
Expedited
N/A
Online Verifications DSS-8650 Notice of Information Needed Earned Income Unearned
Did the DSS-
8650 request The household
Did the DSS- information that was evaluated Did the worker use
8650 request was Correct base using the correct the correct base
Did the worker information inappropriate or Was the client period used or income limit? (net Did worker enter period or
resolve / appropriate for unneeded for given the full 10 income used Income was or gross) (N/A for Earned Income document other
Did the worker address any Was a DSS- eligibility eligibility days to provide documented as calculated categorically correctly on the income as
Case Name run OLV? Hits? 8650 issued? determination? determination? deductions? representative? correctly? eligible) DSS-8590? representative?
Correct
Incorrect
N/A
Yes
No
N/A
Online Verifications DSS-8650 Notice of Information Needed Earned Income Unearned
Did the DSS-
8650 request The household
Did the DSS- information that was evaluated Did the worker use
8650 request was Correct base using the correct the correct base
Did the worker information inappropriate or Was the client period used or income limit? (net Did worker enter period or
resolve / appropriate for unneeded for given the full 10 income used Income was or gross) (N/A for Earned Income document other
Did the worker address any Was a DSS- eligibility eligibility days to provide documented as calculated categorically correctly on the income as
Case Name run OLV? Hits? 8650 issued? determination? determination? deductions? representative? correctly? eligible) DSS-8590? representative?
Yes
No
Categorically Eligible
No
Yes
Immediate
Normal
Expedited
N/A
Unearned Income Deductions Ineligible and Disqualified HH members
Was the
household
evaluated using
the correct income
limit? (net or Did the worker Did the worker Did the worker If yes, did the Did the worker
Did the worker gross) (N/A for enter Unearned Did the HH have Did worker calculate the enter all income Are any members worker evaluate code the HH
calculate the categorically Income correctly income request income income deductions deductions on the of the HH ineligible the HH member member correctly
Case Name Income correctly? eligible) on the DSS-8590? deductions? deductions? correctly? DSS-8590? or disqualified? correctly? on the DSS-8590?
Correct
Incorrect
N/A
Yes
No
N/A
Unearned Income Deductions Ineligible and Disqualified HH members
Was the
household
evaluated using
the correct income
limit? (net or Did the worker Did the worker Did the worker If yes, did the Did the worker
Did the worker gross) (N/A for enter Unearned Did the HH have Did worker calculate the enter all income Are any members worker evaluate code the HH
calculate the categorically Income correctly income request income income deductions deductions on the of the HH ineligible the HH member member correctly
Case Name Income correctly? eligible) on the DSS-8590? deductions? deductions? correctly? DSS-8590? or disqualified? correctly? on the DSS-8590?
Yes
No
Categorically Eligible
No
Yes
Immediate
Normal
Expedited
N/A
Results Comments and Follow up
Was the case Is any action
processed needed to
Case Name correctly? correct case? Comments Follow Up
Correct
Incorrect
N/A
Yes
No
N/A
Results Comments and Follow up
Was the case Is any action
processed needed to
Case Name correctly? correct case? Comments Follow Up
Yes
No
Categorically Eligible
No
Yes
Immediate
Normal
Expedited
N/A
Income Review Sheet
Identifiers Reviewer, Date, Type Earned Income
If base period
income was not The household
used. Was there was evaluated
Type of sufficient Did worker using the
Action (SR, Did worker use documentation calculate correct income
County Date of Type of Application, correct base to support income limit? (net or
Case Name Worker FSIS# Case # Reviewer Review Review Change…) period used? decision? correctly? gross)
Income Review Sheet
Identifiers Reviewer, Date, Type Earned Income
If base period
income was not The household
used. Was there was evaluated
Type of sufficient Did worker using the
Action (SR, Did worker use documentation calculate correct income
County Date of Type of Application, correct base to support income limit? (net or
Case Name Worker FSIS# Case # Reviewer Review Review Change…) period used? decision? correctly? gross)
Correct
Incorrect
N/A
Yes
No
N/A
Yes
No
Categorically Eligible
No
Yes
Immediate
Earned Income Unearned Income Results
If base period
income was not
used. Was there The household Did worker enter
Did worker enter sufficient was evaluated and code Was the
and code Earned Did worker use documentation Did worker using the correct Unearned Income case Is any action
Income correctly correct base to support calculate income income limit? (net correctly on the processed needed to
Case Name on the DSS-8590? period? decision? correctly? or gross) DSS-8590? correctly? correct case?
Earned Income Unearned Income Results
If base period
income was not
used. Was there The household Did worker enter
Did worker enter sufficient was evaluated and code Was the
and code Earned Did worker use documentation Did worker using the correct Unearned Income case Is any action
Income correctly correct base to support calculate income income limit? (net correctly on the processed needed to
Case Name on the DSS-8590? period? decision? correctly? or gross) DSS-8590? correctly? correct case?
Correct
Incorrect
N/A
Yes
No
N/A
Yes
No
Categorically Eligible
No
Yes
Immediate
Comments and Follow up
Case Name Comments Follow Up
Comments and Follow up
Case Name Comments Follow Up
Correct
Incorrect
N/A
Yes
No
N/A
Yes
No
Categorically Eligible
No
Yes
Immediate
Income Deductions Review Sheet
Identifiers Reviewer, Date, Type Request For Verifications Dependent Care Deduction
Did worker Did worker
request income Did the worker Did the worker request Did the worker
Type of deductions on request give the client 10 verification of address
Action (SR, DSS-8650 Notice Was the request verifications that full days to Dependent Care Dependent
County Date of Type of Application, of Information by the worker were provide the Deduction Care
Case Name Worker FSIS# Case # Reviewer Review Review Change…) Needed? correct? unnecessary? deductions? Mileage? Deduction?
Correct
Incorrect
N/A
Yes
No
N/A
Income Deductions Review Sheet
Identifiers Reviewer, Date, Type Request For Verifications Dependent Care Deduction
Did worker Did worker
request income Did the worker Did the worker request Did the worker
Type of deductions on request give the client 10 verification of address
Action (SR, DSS-8650 Notice Was the request verifications that full days to Dependent Care Dependent
County Date of Type of Application, of Information by the worker were provide the Deduction Care
Case Name Worker FSIS# Case # Reviewer Review Review Change…) Needed? correct? unnecessary? deductions? Mileage? Deduction?
Yes
No
Categorically Eligible
No
Yes
Immediate
Dependent Care Deduction Shelter Deductions Medical Deductions Legal Support Obligation Income Exc
Did the
worker enter
Did worker Did the worker Did worker Did the worker Did the worker Did worker use and code the Did worker use
calculate enter and code request take the client's enter and code Did worker correct base Medical correct base
Dependent the Dependent verification of statement for the Shelter request period or Did the worker Did worker Deduction Did worker period or
Care Care Deduction Housing or allowed Deductions verification of document why address calculate correctly on request document why
Deduction correctly on the Utility information such correctly on the Medical base period not Medical Deduction the DSS- verification of base period not
Case Name Correctly? DSS-8590? Deductions? as SUA,TUA,BUA? DSS-8590? Deductions? used? Mileage? Correctly? 8590? LSO? used?
Correct
Incorrect
N/A
Yes
No
N/A
Dependent Care Deduction Shelter Deductions Medical Deductions Legal Support Obligation Income Exc
Did the
worker enter
Did worker Did the worker Did worker Did the worker Did the worker Did worker use and code the Did worker use
calculate enter and code request take the client's enter and code Did worker correct base Medical correct base
Dependent the Dependent verification of statement for the Shelter request period or Did the worker Did worker Deduction Did worker period or
Care Care Deduction Housing or allowed Deductions verification of document why address calculate correctly on request document why
Deduction correctly on the Utility information such correctly on the Medical base period not Medical Deduction the DSS- verification of base period not
Case Name Correctly? DSS-8590? Deductions? as SUA,TUA,BUA? DSS-8590? Deductions? used? Mileage? Correctly? 8590? LSO? used?
Yes
No
Categorically Eligible
No
Yes
Immediate
Legal Support Obligation Income Exclusion (LSO) Results Comments and Follow up
Did the
worker enter
Did worker and code the Was the case Is any action
calculate LSO LSO on the processed needed to
Case Name Correctly? DSS-8590? correctly? correct case? Comments Follow Up
Correct
Incorrect
N/A
Yes
No
N/A
Legal Support Obligation Income Exclusion (LSO) Results Comments and Follow up
Did the
worker enter
Did worker and code the Was the case Is any action
calculate LSO LSO on the processed needed to
Case Name Correctly? DSS-8590? correctly? correct case? Comments Follow Up
Yes
No
Categorically Eligible
No
Yes
Immediate
Timeliness & Appointments Review Sheet
Identifiers Reviewer, Date, Type Normal vs. Expedited & Timely processing
Was the
Did worker worker's
Type of process the determination
Action (SR, cases as of Normal or Did the worker
County Date of Type of Application, Date of Date Normal or Expedited process the
Case Name Worker FSIS# Case # Reviewer Review Review Change…) Application approved Expedited? correct? case timely?
Timeliness & Appointments Review Sheet
Identifiers Reviewer, Date, Type Normal vs. Expedited & Timely processing
Was the
Did worker worker's
Type of process the determination
Action (SR, cases as of Normal or Did the worker
County Date of Type of Application, Date of Date Normal or Expedited process the
Case Name Worker FSIS# Case # Reviewer Review Review Change…) Application approved Expedited? correct? case timely?
Correct
Incorrect
N/A
Yes
No
N/A
Yes
No
Categorically Eligible
No
Yes
Immediate
Normal
Expedited
N/A
Interview Results
Was the
interview If client did not show to
If interview was not scheduled on the first appointment,
conducted on the a DSS-8650 Was the was a second DSS-
Was an Did worker DOA. Was an Notice of interview 8650 sent to let client Was the case Is any action
interview conduct an appointment given Information scheduled know it was up to them processed needed to
Case Name required? interview? to the client? Needed? within 7 days? to contact the agency? correctly? correct case?
Interview Results
Was the
interview If client did not show to
If interview was not scheduled on the first appointment,
conducted on the a DSS-8650 Was the was a second DSS-
Was an Did worker DOA. Was an Notice of interview 8650 sent to let client Was the case Is any action
interview conduct an appointment given Information scheduled know it was up to them processed needed to
Case Name required? interview? to the client? Needed? within 7 days? to contact the agency? correctly? correct case?
Correct
Incorrect
N/A
Yes
No
N/A
Yes
No
Categorically Eligible
No
Yes
Immediate
Normal
Expedited
N/A
Comments and Follow up
Case Name Comments Follow Up
Comments and Follow up
Case Name Comments Follow Up
Correct
Incorrect
N/A
Yes
No
N/A
Yes
No
Categorically Eligible
No
Yes
Immediate
Normal
Expedited
N/A
HH Comp / Size / Disqualifications / Ineligible Review Sheet
Identifiers Reviewer, Date, Type Household Size and Composition
If verification of the HH
size and/or
Was a DSS- Composition was
8650 issued to requested was there Was request for
Type of request sufficient verification too
Action (SR, verification of documentation to limited? (example:
County Date of Type of Application, HH Size and/or support that it is collateral form, HH
Case Name Worker FSIS# Case # Reviewer Review Review Change…) Composition? questionable ? Comp form)
HH Comp / Size / Disqualifications / Ineligible Review Sheet
Identifiers Reviewer, Date, Type Household Size and Composition
If verification of the HH
size and/or
Was a DSS- Composition was
8650 issued to requested was there Was request for
Type of request sufficient verification too
Action (SR, verification of documentation to limited? (example:
County Date of Type of Application, HH Size and/or support that it is collateral form, HH
Case Name Worker FSIS# Case # Reviewer Review Review Change…) Composition? questionable ? Comp form)
Correct
Incorrect
N/A
Yes
No
N/A
Yes
No
Categorically Eligible
No
Yes
Immediate
Ineligible and Disqualified HH members Results
If yes, did the Did the worker Did worker
Are any members worker evaluate code the HH prorate Was the case Is any action
of the HH ineligible the HH member member correctly income where processed needed to
Case Name or disqualified? correctly? on the DSS-8590? appropriate? correctly? correct case?
Ineligible and Disqualified HH members Results
If yes, did the Did the worker Did worker
Are any members worker evaluate code the HH prorate Was the case Is any action
of the HH ineligible the HH member member correctly income where processed needed to
Case Name or disqualified? correctly? on the DSS-8590? appropriate? correctly? correct case?
Correct
Incorrect
N/A
Yes
No
N/A
Yes
No
Categorically Eligible
No
Yes
Immediate
Comments and Follow up
Case Name Comments Follow Up
Comments and Follow up
Case Name Comments Follow Up
Correct
Incorrect
N/A
Yes
No
N/A
Yes
No
Categorically Eligible
No
Yes
Immediate