MDHHS-6053, FAMILIES FIRST PREVENTION SERVICES ACT (FFPSA) NOTIFICATION FOR TRIBES WITH TITLE IV-E AGREEMENT

Michigan Department of Health and Human Services (MDHHS)

(New 6-23)

Procedure for Tribal Government Recommendation of FFPSA Title IV-E

Prevention Services Candidacy for Tribes with Title IV-E Agreements

Definitions:

This form and procedure will be utilized by a tribal caseworker/supervisor when the caseworker/supervisor has identified either:

1.	A child who is an Indian child as defined by the Indian Child Welfare Act (ICWA)/Michigan Indian Family Preservation Act (MIFPA) who is at risk of entering foster care and is in need of FFPSA Title IV-E Prevention Services.

a.	When a child defined as “an Indian child” by ICWA/MIFPA is identified as a candidate for foster care by either MDHHS or a tribal government, the tribal government can manage a prevention record for the child, and/or any siblings who may or may not be defined as “an Indian child” by the ICWA/MIFPA, provided the details are outlined in the IV-E claiming agreement for that tribal government.

or

b.	A child who is not an Indian child as defined by the ICWA/MIFPA who may qualify for FFPSA Title IV-E Prevention Services (as defined in the tribe’s title-IVE agreement).

The intent of Part A of the form is to have the tribal government submit information to MDHHS to recommend FFPSA Title IV-E Prevention Services, or to inform MDHHS of a child who may qualify for services.

The intent of Part B1 of the form is to have MDHHS notify the tribal government of their decision on FFPSA candidacy, and if approved, and initiate data entry into MiSACWIS by the accurate local county.

The intent of Part B2 of this form is for the local county office to notify the tribal government that the MiSACWIS case file has been opened and transferred to the tribal government.

The intent of Part C of the form is for tribal governments to submit an appeal of a denial of FFPSA candidacy to MDHHS.

procedure:

1.	Tribal caseworker obtains family consent to communicate with MDHHS if applicable based on tribal government-specific regulation or statute.

a.	A child who is an Indian child as defined by the ICWA/MIFPA who is at risk of entering foster care and needs FFPSA Title IV-E Prevention Services.

1)	When the tribal caseworker submits Part A of this form, they may submit the information in Part A to verify tribal enrollment/eligibility or attach the tribe’s own Tribal Enrollment/Eligibility Verification Form.

b.	A child who is not an Indian child as defined by the ICWA/MIFPA who may be a candidate for FFPSA Title IV-E Prevention Services.

2.	For FFPSA Title IV-E Prevention Services Form Part A (MDHHS-6053) to the MDHHS Prevention Analyst at: MDHHS-FFPSAPrevention@michigan.gov.

3.	The MDHHS Prevention Analyst will make the FFPSA candidacy determination.

a.	If the Prevention Analyst approves FFPSA candidacy, they will then decide on the accurate county to initiate the creation of the Prevention Record in MiSACWIS by the county office.

1)	The Prevention Analyst will complete part B1 of this form. The Prevention Analyst will then email both Part A and Part B1 of the form to the county office worker and copy the tribal employee who submitted Part A to notify the tribe of their FFPSA candidacy decision, and to which county, and county worker, they sent the approval form.

2)	Once the county worker receives Part B1 of this form, they will begin the MiSACWIS case record, and create the Prevention Record (If the child has an existing case record, the MDHHS caseworker will use the existing Case ID.)

a)	The county worker will upload the Tribal Enrollment/Eligibility Verification Form to the MiSACWIS case record if there was one attached to Part A. See guide: required elements for ICWA cases.

3)	If the tribe indicates that it will be managing the case on Part A, the county worker will complete Part B2 of this form and email it to the tribal supervisor listed on page 2 on Part A of this form to notify them that the MiSACWIS case record has been created, and that the tribe was assigned for case management.

a)	The tribal supervisor will accept case responsibility in MiSACWIS and will assign a tribal caseworker.

i.	The tribal caseworker and supervisor will be responsible for updating the Prevention Record and monitoring ongoing risk and safety of the case.

4)	If the tribe indicates on Part A of the form that they will not manage the case, the county will not send Part B2 of the form with the MiSACWIS case information to the tribe. If the tribe indicates on Part A of the form that they would like to participate in prevention and service planning, the county will email the tribal supervisor listed on Part A to begin collaboration with the tribe.

5)	If the tribe indicates that they do not want to manage the case or be involved in prevention and service planning, the county follows the FFPSA services process.

b.	If the Prevention Analyst denies FFPSA candidacy, they will send Part B1 of this form back to the tribe.

1)	If FFPSA candidacy is denied, the tribe can complete Part C of this form to appeal the decision and send it to the MDHHS State Manager for Prevention and Family Preservation, whose contact information will be listed on Part B1. The tribe needs to email Part C of this form to the MDHHS State Manager for Prevention and Family Preservation to begin the appeal process within 5 business days of when they receive Part B1, the notification of denial.

2)	The MDHHS State Manager for Prevention and Family Preservation will meet with the State Manager for ICWA Compliance and Race Equity to discuss the appeal and make a decision together about the appeal.

3)	If the appeal is approved, the MDHHS State Manager for Prevention and Family Preservation will advise the MDHHS Prevention Analyst to send Part A and Part B1 to the accurate county, and the initiating tribe.

4)	If the appeal is denied for the second time, the MDHHS State Manager for Prevention and Family Preservation will send Part B1 to the tribe to notify of the decision.

5)	If the tribe wants to appeal the decision for the second and final time, the tribe will email all previous forms, Parts A, B1, and C back to the MDHHS State Manager for Prevention and Family Preservation and State Manager for ICWA Compliance and indicate that they want a final appeal process review completed, within 5 business days of receiving the second denial.

a)	The MDHHS State Manager for Prevention and Family Preservation, State Manager for ICWA Cases, Tribal Supervisor, and MDHHS Director will then schedule a meeting to review the case.

b)	If the case is approved, the MDHHS State Manager for Prevention and Family Preservation will notify the MDHHS Prevention Analyst to email Part A and B1 of the forms to the accurate county to begin the case.

The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group on the basis of race, national origin, color, sex, disability, religion, age, height, weight, familial status, partisan considerations, or genetic information. Sex-based discrimination includes, but is not limited to, discrimination based on sexual orientation, gender identity, gender expression, sex characteristics, and pregnancy.

MDHHS-6053, FAMILIES FIRST PREVENTION SERVICES ACT (FFPSA) NOTIFICATION FOR TRIBES WITH TITLE IV-E AGREEMENT

Michigan Department of Health and Human Services (MDHHS)

Part A – Tribal Government Recommendation for FFPSA Title IV-E Prevention Services

section 1 – To be completed by Tribal Caseworker/Supervisor

Date	County of Child’s Residence	Name of Tribal Government

Caseworker Name	Caseworker Phone Number	Caseworker Email

Family Address	City	State	Zip Code

Family Phone Number	Child’s Tribal Affiliation

section 2 – Purpose of the Form (check one)

. 1. Tribal recommendation that an Indian child as defined by the ICWA/MIFPA is at risk of removal.

2. Referral of child who is not an Indian child as defined by the ICWA/MIFPA who is potentially at risk of removal.

2a. Tribe would like to participate in prevention and services planning.

2b. Tribe would not like to participate in prevention and services planning.

section 3 – if tribal recommendation of Indian child as defined by the ICWA/MIFPA

Does notifying tribe have Title IV‐E Prevention Agreement with the State? (Check Yes or No) Yes No

If yes, will tribe be managing this case (Check Yes or No) Yes No

Is the Tribal Enrollment / Eligibility Verification attached? Optional (Check Yes or No) Yes No

section 4 – Fill out this table for all identified children, regardless of tribal enrollment or eligibility:

Relationship	Name	Date of Birth	Gender	Phone Number	Focus Child*	Relationship to Child	Tribally Enrolled or Eligible?	Enrollment Date of Child	Tribal Enrollment Identification Number (optional)
Parent/ Caregiver 1	N/A	N/A
Parent/ Caregiver 2	N/A	N/A
Parent/ Caregiver 3	N/A	N/A
Child	N/A
Child	N/A
Child	N/A
Child	N/A
Child	N/A

*Definition of Focus Child: The primary child this is identified as eligible for FFPSA Title IV-E Prevention Services

section 5 – Check identified reason(s) for FFPSA Title IV‐E Prevention Services eligibility and attach supporting documentation as required in corresponding pathway (select all that apply)

A child for whom abuse or neglect has been confirmed

Date of tribal investigation	Date of tribal CPS Case Closure

A child for whom maltreatment has not been confirmed but low to intensive risk for maltreatment exists.

Date tribal investigation ended

Infant born exposed to substances

Substance use identification method (Parental disclosure; physician)

A child whose adoption or guardianship arrangement is at risk of disruption or dissolution

A child with delinquent behaviors under supervision of MDHHS

A child of a parent who had been in foster care (until the parent reaches age 26)

Date entered into Foster Care

A child who is in foster care and pregnant or parenting

A child who was in foster care and returned to their parents or relative

Date returned home	Date of Foster Care Case Closure (if applicable)

Based on candidate box checked, give a detailed summary of the needs that have been assessed for the family/child.

section 6 – tribal government Supervisor Signature (verifying information is correct)

Tribal Government Supervisor Signature	Date

Name of Tribal Government Supervisor	Email of Tribal Government Supervisor

Part B1 – MDHHS Notification to Tribal Government and County Office

of FFPSA Title IV-E Prevention Services Decision

section 7 – To be completed by MDHHS Prevention Analyst

Tribal Notification Date	FFPSA Title IV‐E Prevention Services Candidacy Decision Date

MDHHS Candidacy Decision Approved Not Approved

If Appeal Decision Approved Not Approved

Check One of the following options:

1. FFPSA Title IV‐E Prevention Services Candidacy is approved, and Tribe will Manage prevention record.

Attach Tribal Enrollment/Eligibility Verification Form, if submitted with Part A

2. FFPSA Title IV‐E Prevention Services Candidacy is approved, and Tribe is not managing CSPP.

3. FFPSA Title IV‐E Prevention Services Candidacy is approved, and child is not an Indian child as defined by ICWA/MIFPA.

4. FFPSA Title IV‐E Prevention Services Candidacy is Not Approved.

Provide reason below.

MDHHS will send Appeal Process Reference to individual who submitted Part A of this form.

section 8 – MDHHS employee signature (verifying information is correct)

MDHHS Employee Signature	Date

Name of MDHHS Employee	Email of MDHHS Employee

Name of MDHHS State Manager for Prevention and Family Preservation	Email of MDHHS State Manager for Prevention and Family Preservation

section 9 – ffpsa candidacy approval – if FFPSA Candidacy Approved, the Prevention Analyst will send both Part A and Part B1 of this form to the accurate county office, listed below.

County Office Name	County Office Email

County Office Employee Name	County Office Employee Email

Part B2 – County Office Notification to Tribal Government

of MiSACWIS Case Assignment

section 10 – FFPSA Title IV‐E Prevention Services Candidacy was approved by MDHHS.

MiSACWIS Record Creation Date	MiSACWIS Case ID

Tribal Enrollment/Eligibility Verification Form was uploaded to MiSACWIS, if attached to Part A

Date case transferred to Tribal Supervisor

section 11 – COUNTY employee signature (verifying information is correct)

County Employee Signature	Date

County Employee Name	County Employee Email

County Employee Supervisor Name	County Employee Supervisor Email

Send Part A, Part B1 and Part B2 of this form to tribal employee listed in Part A of this form.

Part C – Tribal Government Appeal for FFPSA Title IV‐E Prevention Services

This appeal form should only be used by Tribal Governments for Indian children as defined by ICWA/MIFPA to appeal the MDHHS decision to not provide FFPSA Title IV‐E Prevention Services to the child and their family. This form should be sent to the MDHHS State Manager for Prevention and Family Preservation, as listed in Part B1.

section 12 – To be completed by Tribal Worker/Supervisor

Date of Appeal	County of Child’s Residence	Name of Tribal Government

Worker Name	Worker Phone Number	Worker Email

Family Address	City	State	Zip Code

Family Phone Number	Child’s Tribal Affiliation

Explanation of Appeal

section 13 – tribal employee signature (verifying information is correct)

Tribal Employee Signature	Date

Tribal Employee Name	Tribal Employee Email

MDHHS Prevention Analyst will send a new version of Part B1 of this form to the tribal employee, and county office to answer this appeal.