FSET Enrollment Forms

FSET Participation Agreement

WISCONSIN DEPARTMENT OF HEALTH SERVICES Division of Medicaid Services F-00136 (03/2019)7 CFR pts. 271 and 273

FSET Program Rules and Responsibilities

You must meet the following program rules to take part in the FSET Program:

• Be getting FoodShare benefits.
• Be at least 16 years old.
• Work with your FSET worker to create an employment plan that includes your employment goals, action steps, and activities.
• Talk with your FSET worker at least once a month about taking part in the FSET program.
• Attend and take part in scheduled, assigned appointments. If you are unable to keep an appointment or may be late, notify your FSET workerbefore the appointment. If you are unable to contact your FSET worker before the appointment, do so as soon as you are able.
• Turn in your attendance information for assigned activities. For some activities, the FSET worker will do this for you. Work with your FSET worker to determine the types of proof that you must submit for each assigned activity.
  Inform your FSET worker if you are no longer interested in taking part in the FSET program.
• Use FSET support services, such as help with transportation, for FSET activities only

File a Complaint, Concern, or Fair Hearing Request
If you have complaints or concerns about FSET services, you can speak with your FSET worker about your concerns and the process for filing a grievance (complaint). If your grievance cannot be resolved with the local FSET agency, you have the right to file for a fair hearing. You can ask for a fair hearing by writing or calling:

Division of Hearing and Appeals, P.O. Box 7875, Madison, WI 53707-7875

Phone: 608 -266-7709 • Fax: 608-264-9885

You can get the Request for Fair Hearing form at www.dhs.wisconsin.gov/forwardhealth/resources/htm

The Division of hearing and Appeals must get your request no more than 90 days from the date of the action.

You can also contact your local agency by phone, in person, or in writing to ask for a fair hearing. To find your local agency, visit www.dhs.wisconsin.gov/forwardhealth/imagency/index.htm or call Member Services at 1-800-363-3002.
 

USDA NONDISCRIMINATION STATEMENT 

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, this institution is prohibited from discriminating on the basis of race, color, national origin, sex (including gender identity and sexual orientation), religious creed, disability, age, political beliefs, or reprisal or retaliation for prior civil rights activity.

Program information may be made available in languages other than English. Persons with disabilities who require alternative means of communication to obtain program information (e.g., Braille, large print, audiotape, American Sign Language), should contact the agency (state or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339.

To file a program discrimination complaint,  a Complainant should complete a Form AD-3027, USDA Program Discrimination Complaint Form which can be obtained online at: https://www.usda.gov/sites/default/files/documents/ad-3027.pdf, from any USDA office, by calling (833) 620-1071, or by writing a letter addressed to USDA. The letter must contain the complainant’s name, address, telephone number, and a written description of the alleged discriminatory action in sufficient detail to inform the Assistant Secretary for Civil Rights (ASCR) about the nature and date of an alleged civil rights violation. The completed AD-3027 form or letter must be submitted to:

 
(1) Mail: 

     Food and Nutrition Service, USDA  

     1320 Braddock Place, Room 3344,

     Alexandria VA 2214

(2) Fax: (833) 256-1665 -or- (202) 690-7442

(3) email:FNSCivilRightsComplaints@usda.gov

This institution is an equal opportunity provider.

Support Services Agreement Form

By receiving support services, you agree to the following:

• I will use my support services to complete FSET activities listed on my Employment Plan.
• I will turn in documentation to my case manager showing completion of my FSET activities.
• I understand that if I receive assistance but then do not do my activities, I may not be able to receive additional assistance until I complete those activities.
• If I receive gas cards, I will track the miles I travel to complete my FSET activities and will receive gas cards based upon how many miles I traveled for FSET activities.
• If I do not have a valid driver’s license or vehicle, I can use gas cards for someone else to take me to and from my FSET activities. 
• If I am traveling to do job search more than 10 miles, I understand I need to apply for more than one job per trip. It is expected I make at least five (5) employer contacts unless the trip is for a scheduled job interview, job fair or similar event. My case manager may grant an exception based upon my circumstances.
• I will be granted good cause if FSET does not have the funding to pay for allowable support services.

I may lose my right to receive future support services if I:

• don’t follow the above agreement, or
• falsely report activity to receive support services, or
• sell, trade, or falsely report support services being lost or stolen.

If you have complaints or concerns about your FSET services, ask to speak with your FSET Case Manager about your concerns and the process for filing a complaint. If your complaint cannot be resolved with the local FSET agency, you have the right to file for a fair hearing.

Agreement on Use of Electronic Mail for Client Communications

This Agreement on the Use of Electronic Mail (E-mail) for Client Communications is between the NorthCentral FSET Program [Wood County Human Service Department (WCHSD)/CW Solutions] and an individual client

WCHSD and CW Solutions have guidelines about the use of e-mail communications.

1. Use of E-mail Communications. You may use e-mail about your care, treatment or administrative matters with WCHSD/CW Solutions. If you are experiencing an emergency or need an immediate response, call WCHSD/CW Solutions by telephone or come to our offices. E-mail should not be used for emergencies or when you need a quick response. WCHSD/CW Solutions will generally return an e-mail message within two (2) business days. If you do not receive a response by five o’clock on the second day, then call or visit us the next day. We will use our professional judgment to decide when a response by e-mail is appropriate or practical. We may reply to your e-mail by mail. We may also request that you either speak with us by telephone or make an appointment for an in-person visitWCHSD/CW Solutions staff may use email for things like confirming appointments, setting up meetings, or scheduling court dates. Email generated by WCHSD that are not in response to client’s email should not contain confidential case-related information.
2. Composing E-mail Messages. E-mail messages should include your full name, date of birth, and a description of why you are sending us an e-mail message and how we can help you.
3. Access to Client's E-mail Communications. It may be necessary for WCHSD staff, other than the staff to whom the message is sent, to access e-mail messages, in order to provide a timely response. This agreement allows any WCHSD/CW Solutions staff to access your e-mail messages.
4. No Liability. You agree that e-mail communications with WCHSD is offered as a convenience to yourself. You shall not hold us responsible for any expense, loss, or damage caused by, or resulting from: (i.) a delay in the our response to your e-mail, or any damage to you resulting from such delay, due to technical failures, including, but not limited to, technical failures caused by an internet service provider, power outages, failure of the electronic messaging software, failure by our staff or yourself to properly address e-mail messages, failure of our computers or computer network, or faulty telephone or cable data transmission; (ii.) any interception of e-mail communications by a third party; or (iii.) your failure  to comply with these guidelines.
5. Confidentiality. WCHSD/CW Solutions will exercise reasonable efforts to ensure the confidentiality of your e-mail. However, e-mail communications are not secure, and there is some possibility that another party may gain illegal access to your e-mail messages. Communication about highly confidential matters should not be discussed in your e-mail messages. You should telephone, write a letter, or personally visit us about highly confidential matters. It is important to remember that email sent from your computer are accessible to anyone who has access to your computer, unless you place them in a password protected folder or unless you delete them from both your email system and your trash folder. WCHSD is not responsible for privacy of information stored on your computer.
6. Archiving. WCHSD/CW Solutions may keep copies of e-mail messages you send.
7. Termination. Either WCHSD/CW Solutions or you may terminate this Agreement at any time or for any reason.

 

Text Message Agreement

• I understand my worker is only available during their work hours. FSET standard hours are 8am – 4:30pm, Monday – Friday, though some workers have a different schedule. A worker may not be available during work hours if they are meeting with other customers, in a meeting, or out of the office. My worker will respond within two business days. I know I can always call the Main Office number during business hours if I need to speak to someone immediately.
• If I have an emergency, I understand I should call 911, my local Crisis Line, or other emergency service numbers.
  Messages are not confidential as they may be monitored by the worker’s employer.
• Messages may be saved as part of my case record.
• I agree not to message/tag/etc. workers on their personal social media accounts.
• If I send inappropriate messages (soliciting, harassing, or threatening) via text or to the worker’s personal social media accounts, I may lose access to some or all program services.
• I will report any concerns about messages I receive from my worker to a manager by calling 715-421-8608.
• I can revoke the option to communicate via text messages by informing my worker verbally or via text message, email, or other forms of writing.

I have read and I understand the contents of these document. My questions have been answered, and a copy of this form was provided to me.

NorthCentral FSET Program

Main Office: 111 W Jackson St, Wisconsin Rapids WI 54495

(715) 421 - 8608

www.myFSET.net 

This institution is an equal opportunity provider