Consumer’s work skills, conditions, preferences and interest
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(Recommend other pertinent consumer information be shared with the provider
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Provider Contact Name: Phone: Email
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https://www.dcf.ks.gov/services/RS/Documents/service_descriptions/Contracts/Section 11 Part-24_Service_referral_form.pdf
Between Kansas Department for Children and Families
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University of Kansas Medical Center Research Institute, Inc. (Project Eagle
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**A copy of any previously approved Renewal(s) and/or
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https://www.dcf.ks.gov/Agency/Operations/NOGA/Documents/KU Project Eagle HV Renewal 1 and 2 SFY23-24.pdf
RENEWAL#: Form OGC-1010.2 REV 2/19 DCF Program may request a Renewal if they would like to
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KS 67208 Grant Year (from/to) E-Mail blippe@mhasck.org 7/1/2022 6/30/2024 Phone Number 316
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https://www.dcf.ks.gov/Agency/Operations/NOGA/Documents/Mental Health Assoc of S.C KS Renewal 1 SFY23.pdf
Authorized Project Official- I certify that to the best of my knowledge and belief, this report is true in all respects and that all
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disbursements have been made for the purpose and
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https://www.dcf.ks.gov/services/RS/Documents/CIL RFP 4 Counties/Attachment_E4_Monthly_Fiscal_PDF Final.pdfView duplicates
Agency: Street Address* City, State, Zip* E-Mail Phone Number Fax Number Between Kansas
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https://www.dcf.ks.gov/Agency/Operations/NOGA/Documents/Independent Connection Inc CIL Renewal 1 and 2 SFY23.pdf
This fonn must be submitted to your DCF OGG Grant & Contract Specialist for submission through
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KS 67203 Grant Year (from/to) E-Mail cunruh@ilrcks.org 7/1/2023 6/30/2024 Phone Number
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https://www.dcf.ks.gov/Agency/Operations/NOGA/Documents/Independent Living Resource Center CIL Renewal 1 and 2 SFY23.pdf
Number EES-2021-ITSN-01 City, State, Zip* E-Mail 7/1/2021 6/30/2022 Phone Number Fiscal Year
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https://www.dcf.ks.gov/Agency/Operations/NOGA/Documents/KCCTO ITSN Amendment 1 and 2 FY22-24.pdf
to); Ff (Fax from); Et (E-mail to); Ef (E-mail from); Check Mark for Health
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https://www.dcf.ks.gov/services/PPS/Documents/PPM_Forms/Section_1000_Forms/PPS1010.pdf
The Department for Children and Families (DCF) has received and investigated a report of abuse, neglect, or exploitation of the involved adult named
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Adult Protective Specialist Email
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https://www.dcf.ks.gov/services/PPS/Documents/PPM_Forms/Section_10000_Forms/PPS10350.pdf
PPS 10370 January 2018 ANE Unit
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Prevention and Protection Services- Adult Protective Services
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Email Address
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https://www.dcf.ks.gov/services/PPS/Documents/PPM_Forms/Section_10000_Forms/PPS10370.pdf