Promising Practices on Application Forms
(Electronic Version Updated in June 2003)
Important Note: What follows are examples of state approaches to reducing access barriers faced by vulnerable populations on application forms for federal public benefits. These states have endeavored to design forms so that questions encourage participation by racial and ethnic minorities and persons with disabilities. They also have developed welcoming messages such as offers of assistance and assurances of confidentiality of sensitive information. These are by no means the only states that have developed these promising practices, but these examples have been chosen to illustrate different approaches. The packet is offered for use by states that are seeking to revise current forms that may discourage immigrant families and others from applying.
These examples were assembled by the national Application Workgroup of the HHS Office for Civil Rights (OCR). OCR has made no formal civil rights findings with regard to the forms in this packet and not everything in the following sample pages is endorsed by OCR as a "model" for others to follow.
TEXAS DEPARTMENT OF HUMAN SERVICES
List of Forms and How to Apply (Versions available in English and Spanish): http://www.dhs.state.tx.us/Forms/Form1010.html
Application for Assistance Part A: Information You Need to Know (Form 1010-A/01-2003) (Bilingual English-Spanish)
Part A, Page 1. The section on "Important Information for Immigrants" explains which family members need to provide Social Security Numbers ("SSNs") and immigration status information. It also addresses public charge concerns and explains when applying for public benefits may or may not affect immigration status. Part A, Page 3. Communicates that information on race and ethnicity is optional, does not affect eligibility, and is used to protect civil rights. Explains in detail which family members' SSNs are required and which are optional, how the agency uses SSNs, and includes reassurance that SSNs will not be shared with the Immigration and Naturalization Service ("INS," now the Bureau of Citizenship and Immigration Services, or BCIS). Clarifies again that only applicants need provide immigration status information.
Application for Assistance Part B: Information We Need to Know (Form 1010-B/10-2002) (Bilingual English-Spanish)
Part B, Page 1. Uses plain language in asking what types of help with services are needed. Checkbox for person with a disability. Part B, Page 2. Another checkbox for person with a disability. Asks about the need for special accommodations and interpretation. "Instructions" establishes symbols that identify questions relevant to food stamp, Medicaid, and TANF eligibility (so if a family is eligible for only one or two of these programs, they can skip irrelevant questions). Part B, Pages 3 & 4. Section for "Household Information" is separated into two blocks for applicants (page 3) and non-applicants (page 4), requiring SSN and citizenship information only of applicants.
MARYLAND DEPARTMENT OF HUMAN RESOURCES
Bilingual English-Spanish List of Forms: http://www.dhr.state.md.us/fia/forms.htm
Facts You Should Know about Applying for Temporary Cash Assistance, Food Stamps and Medical Assistance (DHR/FIA CARES 9701A (3/02) (Also available in Spanish)
Clarifies need for and uses of SSNs, including statement that SSNs are not shared with INS/BCIS, and which family members need to provide immigration status information. Communicates that there are no requirements for SSN or immigration status if applying for Emergency Medicaid. Offers help and language assistance; offer is also translated into Spanish.
Application for Assistance (DHR/FIA CARES 9701 (Revised 3/02) (Also available in Spanish)
Page 1. Asks, "What language do you speak?," and offers language assistance. Uses plain language in asking what types of assistance are needed. Checkbox for person with a disability. Page 2. Section for "Household Members" is divided into two separate blocks: one for "everyone who lives with you" and the second for "each person who wants benefits." Only those who want benefits are asked for SSNs and citizenship and immigration status information. Helpful messages about the use of information on race and, in Section B, about confidentiality of immigration information, and eligibility for Emergency Medicaid regardless of immigration status.
IDAHO DEPARTMENT OF HEALTH AND WELFARE
Bilingual English-Spanish Information on Benefits and Financial Assistance, Including Application Form: http://www2.state.id.us/dhw/benefits/benefits_and_assistance.htm
Application for Assistance (HW 2000, Revised 11/2001) (Also available in Spanish)
Cover Sheet. Offers language assistance and an application form in Spanish; offer is also translated into Spanish. "Instructions" include a helpful message about confidentiality and public charge concerns. Page 1. Asks, "What is your preferred language?" for both spoken and written languages. Communicates to victims of domestic violence that absent parent information need not be provided if persons completing the form "fear harm to yourself or your children," and that absent parent information is not needed if applying only for children's medical coverage. Page 2. Separate blocks: the first is for "each person who lives in your home" and the second is "only for people requesting benefits," and only the latter are asked for SSNs and citizenship information. Communicates that information on race is optional, and that applicants may select more than one racial/ethnic category.
WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES
List of Electronic DSHS Forms: http://www.dshs.wa.gov/dshsforms/forms/eforms.html
Application for Benefits (DSHS 14-011 (REV. 04/2002) (AC 02/2003)
(Also available in Albanian, Amharic, Arabic, Bulgarian, Bosnian, Cambodian, Chinese, Farsi, Hindi, Hmong, Hungarian, Illocano, Italian, Japanese, Korean, Laotian, Oromo, Punjabi, Polish, Romanian, Russian, Swahili, Somali, Spanish, Tagalog, Thai, Tigrigna, Ukrainian, and Vietnamese)
Page 2. Uses plain language in asking what types of help are needed. Asks if sign or language interpreter is needed. Communicates that information on race and ethnicity is optional, does not affect eligibility, and that applicants may select more than one racial/ethnic category. Question 18 communicates that SSN and citizenship information is optional for nonapplicants.
NEW YORK DEPARTMENT OF HEALTH
Family Health Plus Application Website: http://www.health.state.ny.us/nysdoh/fhplus/application.htm
Access NY Health Care Application
(DOH-4220) (Also available in Spanish)
Page 2. Section D clarifies that only applicants need to provide immigration status information and that there is a state-funded program for immigrant children who do not qualify for federal programs. It lists under "A" immigrant categories that confer eligibility for federal programs, and under "B" immigrant categories that confer eligibility for the state program, without asking any child's immigration status.
TENNESSEE DEPARTMENT OF HUMAN SERVICES
Tennessee DHS Website: http://www.state.tn.us/humanserv/
Application/Review of Eligibility for Families First, Food Stamps, Medicaid/ TennCare Standard (HS-0169 (Rev. 11/02) (Also available in Spanish)
Page 1. Option to check "I do not want to apply" for Families First, food stamps, or Medicaid. Important-Keep this Paper. Offers language and special assistance for people with limited English proficiency or a disability, and translates this offer into Spanish. Clarifies which family members need to provide SSNs and citizenship status information and that this information is not required if applying for Emergency Medicaid. Explains how the information will be used and that it will not be reported to the INS.
MINNESOTA DEPARTMENT OF HUMAN SERVICES
Minnesota DHS Electronic Document System (eDocs): http://edocs.dhs.state.mn.us
Combined Application: Cash Assistance, Food Support, and Health Care
(DHS-3469-ENG (11-02) (Also available in Arabic, Hmong, Khmer, Lao, Oromo, Russian, Serbo-Croatian-Bosnian, Somali, Spanish, and Vietnamese)
Page 1. Asks for primary spoken and written language and the need for an interpreter. Offers forms in alternative formats for people with disabilities. Clarifies that only applicants need to provide SSNs. Page 5. Question 2 provides option to check "no" if "someone in your household does not want to apply" for cash assistance, health care, food support, or emergency programs. Communicates that information on race/ethnicity is optional and that applicants may select more than one racial category. Page 6. Note in question 7a clarifies that only applicants must provide immigrant status information.
Last revised: November 7, 2003
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