Instructions for Completing the Referral for Monitoring and Technical Assistance Form
- It is not always necessary to enter names of individuals on the form or to specify site information. If there are issues that are agency-wide and do not specifically apply to any individual or site, the sections for individuals' names and site addresses may be left blank.
- If more than 4 people are concerned at the site, include the remaining individuals' names in the description or attach a separate page.
- If concerns are site-specific, do not include more than one site on a form.
- You may install this form in a word processor and expand its length if necessary.
- Send a copy to the primary direct service provider for each individual listed on the form and to any providers listed on the form.
- Send the form to:
Illinois Department of Human Services
Division of Developmental Disabilities
600 East Ash, Building 400, Mail Stop 3
Springfield, IL 62703
Fax: (217) 558-2799
ISSAs may identify additional situations for which referrals are also appropriate. The following guidelines indicate some situations for which referral to the Division is indicated: