CLIENT CONFIDENTIALITY: Any information provided to KANA Community Services staff as part of the Client Intake Form submission process will be kept confidential and will not be shared without the client's prior authorization.

INTAKE FORM ASSISTANCE AVAILABLE: If you or someone you know needs assistance completing this Client Intake Form please reach out to Community Services staff via phone (907-486-9879) or email (477Eligibility@kodiakhealthcare.org). Free language translation services are available upon request to individuals with limited English proficiency.

AVAILABLE SERVICES: Please select the service(s) that you are applying for below:

ELIGIBILITY REQUIREMENTS: Additional documents may be needed for program-specific assistance.

1. Completed Client Intake Form (all sections fully addressed)*

*Individuals seeking emergency shelter services are not required to complete the Client Intake Form. Please call 907-486-7305 or email tvs@kodiakhealthcare.org for emergency shelter services.

2. Provide proof of Alaska Native/American Indian status, if applicable*

*Child Care Assistance and select Family Support Services are based on child status.

You can submit documents electronically at the end of this form.

3. Currently reside in Koniag Region (Akhiok, Karluk, Kodiak, Larsen Bay, Old Harbor, Ouzinkie, or Port Lions)*

*Akhiok and Port Lions Scholarship applicants need not reside within the Koniag Region.

4. Selective Service verification for males 18+, if applicable

 

INTAKE PROCESSING & FOLLOW-UP:

• Completed Client Intake Form will be processed within 10 business days
• Client will receive notification(s) via phone, email, or mail based on the preferred contact method selected
• Complete and return supplemental program form(s) and additional documentation, if applicable
• Schedule and attend an intake meeting with a Community Services staff member

Parent/Guardian signatures are required for non-emancipated youth under 18 years of age*

*Parent/Guardian consent is not required to receive Survivor Support Services, per applicable State and Federal laws

PRIMARY NEEDS: (check all that apply)

CERTIFICATION STATEMENT: I certify that the information provided is accurate to the best of my knowledge and agree to update Community Services staff as needed during my participation. I have received and understand my rights under the Community Services appeals process.

Please upload the following documents if applicable:

• Certificate of Indian Blood (CIB) or Tribal Card
• Driver's License or Photo Identification Card 

An applicant has the right to appeal any decision made by KANA's Community Services division regarding their services. The appeal process is to be conducted in writing and within specified time frames. An applicant may withdraw their appeal at any point during the three-step process detailed below.*

Step 1: Participant

Participants must submit a written complaint to KANA's Community Services division staff within five business days of the decision. Complaints must include the name of the staff member, details of the participant's concern, and the desired action or remedy. Written complaints may be delivered to the following locations:

Email Address:

Subject: 477 Appeals

477Eligibility@kodiakhealthcare.org

Mailing Address:

Attn: 477 Appeals

3449 E Rezanof Dr | Kodiak, AK 99615

Physical Drop-Off:

Attn: 477 Appeals

111 W Rezanof Dr | Kodiak, AK 99615

OR

Attn: 477 Appeals

194 Alimaq Dr | Kodiak, AK 99615

Step 2: Program Supervisor

The appropriate program supervisor will have five business days to respond to the participant's complaint and arrange a meeting. If the grievance is not resolved during the meeting with the appropriate program supervisor, the participant may proceed to Step 3.

Step 3: Grievance Committee

Should the participant be unsatisfied with the determination made by the program supervisor, the participant must submit a written complaint within five business days of the program supervisor's response. Once the written complaint is received, a Grievance Committee will convene within five business days of receipt to consider the participant's complaint and review the handling of the initial appeal. Once convened, the Grievance Committee will have an additional five business days to respond to the participant's escalated complaint and render a final decision.

*In addition to this Appeal Process for Community Services division programs in general, Vocational Rehabilitation clients may also contact the Alaska Statewide Independent Living Council Client Assistance Program (CAP), a client advocacy organization that may be able to provide client assistance or support. For more information call 1-800-478-0047 or see https://www.alaskasilc.org/resources/client-assistance-program/