Domestic Abuse Forms

Authorization For Release of Information (SCD 1029)

The SCD 1029 may be used as a release to obtain information to assist the client to identify and remove barriers to employment and self-sufficiency.

Permission To Release Domestic Abuse Information When Moving To Another County (WTW 37)

The WTW 37 must be provided to the client in the event they move to another county. They have the option to have our county share with the new county any domestic abuse-related information we may have in their current case record.

CalWORKs Domestic Abuse Participation Status (SCD 1554)

The CalWORKs Social Worker (SW)/Domestic Violence (DV) Advocate will use the SCD 1554 to offer the client the opportunity to utilize the following options:

Domestic Abuse Exemption/Extender Determination

The top portion of the SCD 1554 is completed by the CalWORKs SW/DV Advocate to:

List the date the client was seen/contacted
Identify the CalWORKs client’s case status as pending or active
Approve a Domestic Abuse Exemption/Extender and document the approved time period
Deny a Domestic Abuse Exemption/Extender because it either does not unfairly penalize or is not detrimental to the well-being or safety or the survivor of their family
Inform the Employment Counselor (EC) that an integrated domestic abuse WTW plan may be developed
Notify the EC and the Eligibility Worker (EW) when the client has declined the Exemption/Extender or failed to keep their appointment
Extend a Domestic Abuse Exemption/Extender when appropriate and list the new expiration date
Initiate a Local Child Support Agency (LCSA) Child Support Domestic Abuse Good Cause request
Send a copy of the SCD 1554 to the EC and the EW
Document the date the EC and EW were sent a copy of the form
List supportive services the client may need during the Domestic Abuse Exemption/Extender period in order to support the domestic abuse WTW activities.

Child Support Domestic Abuse Good Cause

The CalWORKs SW/DV Advocate will advise the client of the option of claiming “Good Cause” due to domestic abuse in order to prevent a child support referral to the LCSA to establish paternity and child support. The CalWORKs SW/DV Advocate will also advise the client of domestic abuse waivers of child support and maternity/paternity establishment.

Alternate Mailing Address/Safe At Home Program

If the client chooses to use an alternate mailing address, P.O. Box number, or telephone number, they must complete the "Client Completes for Alternate Mailing Address" section of the SCD 1554.

If the client is enrolled in the Safe at Home (SAH) program, this information will be accepted and recorded by the EW. The middle section of the SCD 1554 must still be completed by the client.

For more information on the Safe at Home (SAH) program, refer to Common Place Handbook "SSA Protective and Supportive Services Overview."

Exception: When factors affecting eligibility or apparent eligibility, such as in cases of immediate need, diversion, or suspected fraud, cannot be satisfactorily determined, the applicant/recipient is required to provide the actual residence address. This information is to be maintained in the case file only and is not to be entered on any computer/automated system. Continue to use the Safe at Home P.O. Box and fictitious street address on all computer-generated documents.

SCD 1554 Distribution

The SCD 1554 is distributed as follows:

The CalWORKs SW/DV Advocate
- Retains the original SCD 1554.
- Emails the SCD 1554 to the assigned EC and SW CST.
- Provides a copy to the client, upon their request.
The CalWORKS SW CST
- Images the SCD 1554.
- Creates a task for EW to follow up.

EW and EC Coordinated Review and Action

When the SCD 1554 is received from the CalWORKs SW/DV Advocate, EWs and ECs must review the form and take the following actions:

EWs

Add the case flag "Domestic Abuse" and enter an end-date 30 days out.
Enter the alternate mailing address, if one is chosen.
Sign and date the bottom of the SCD 1554.
E-mail a completed copy of the SCD 1554 to the EC and the CalWORKs SW/DV Advocate.
Receive e-mail notification from the EC that the Maintain Participant Activity window in CalSAWS has been updated with the activity:
1. "Domestic Abuse SV" activity for exemptions, or
2. Extender-Domestic Abuse Service for Extenders, and Registration status of “Exempt” with Exemption Reason of “Manual Exemption: Domestic Abuse (CalWORKs 60-month time limit waiver).
Run EDBC.

ECs

Refer to the CalWORKs Domestic Abuse Participation Status (SCD 1554) topic in CWES Handbook Chapter 23.