OTDA Home Programs & Services Shelter Oversight and Compliance Application for Certification & Forms
Application for Certification
Contact the Division of Shelter Oversight and Compliance at 518-486-4040 or otda.sm.css.bss@otda.ny.gov for questions regarding forms and regulations.
Operational Plan Filing Instructions
Emergency Shelter Operational Plan
- Emergency Shelter Operational Plan Adult or Adult Family Shelters
- Emergency Shelter Operational Plan Family Shelters
- Request for Regulation Waiver Form
Security Plan
Budget
Forms
The pre-approved sample forms listed below may be adopted as necessary to comply with shelter operating standards.
Administrative Forms
- Schedule of Staffing
- Chronological Admission Registry
- Chronological Discharge Registry
- Emergency Family Information
- Family Census
- Individual Sign-In/Sign-Out Sheets
- Overnight Pass Application
- Incident Report
- Category of Incidents
- Numerical Listing of Incidents
- Resident Suggestion/Complaint
- Staff and Volunteer Training Log
- Security Guard Licenses
- Mail Log
- Internal Monthly Report
- Family Master List
- Program Support Documentation
- Resident Intake Starter Kit
- Resident Warning Notice
- Resident Request for Pre-Discharge Hearing
- Notice of Scheduled Pre-Discharge Hearing
- Resident Acknowledgement of Pre-Discharge Hearing
- Tier II Request for Resident Transfer
- Notice of Involuntary Transfer (Spanish)
- Involuntary Transfer Hearing Decision (Spanish)
- Notice of Involuntary Transfer
- Involuntary Transfer Hearing Decision
Program Forms
- Family Currently Employed
- Enrolled in Job Training/Education Programs
- Enrolled in Mental Health/Addictions Treatment Program
- Weekly Caseworker/Housing Activity Report Instructions
- Weekly Caseworker/Housing Activity Report
- Monthly Caseworker/Housing Activity Report
- Permanent Housing Placements
- Apartment Inspection Form
- Daily Childcare Attendance
- Childcare Waiting List
- Resident Childcare Instruction
- Resident Childcare Agreement
- Authorization to Use Resident Childcare
- Resident Childcare Attendance
- Facility School Age Attendance Obligations
- Daily School Departure/Attendance
- School Non-Departure Form
- School Non-Departure Form Instructions
- Sample Childcare and Recreation Food Menu
- Daily Recreation Attendance
- Case Manager’s Resource Guide
Client Forms
- Resident Acknowledgment of Forms, etc
- Family Case Record Admission/Assessment
- Emergency/Immediate Needs Determination
- Preliminary Health Screening
- Screen I Medical
- Service Plan/Independent Living Plan Instructions
- Service Plan/Independent Living Plan Form
- Amended Service Plan Agreement
- Temporary Housing Assistance (THA) Responsibility
- Service Plan/Independent Living Plan Samples
- Quarterly Assessment to Determine Self-Sufficiency
- Consent for Disclosure of Medical and Non-Medical Records
- Consent for Disclosure Release of Mental Health Records
- Notice about Signing the Required Consent for Disclosure
- 30 Day Case Management (Resident Case Referrals)
- History/Progress Notes
- Housing Plan
- Resident Confirmation of Attempt to Seek Housing
- Notification of Housing Linkage
- Apartment Inspection Checklist
- Relocation Case Summary (RCS)
- Relocation Case Summary Codes
- Conditional Family Immediate Needs Determination
- Cluster-Hotel-Motel-Scatter Site Intake Assessment
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