SAWs Client Intake Form - IN Header Image

Indiana Referring Partner Client Intake

All required fields with * must be completed. After submission, the form will go to a SAWs Customer Service Representative for review.

If approved, SAWs will contact the client directly.

If not approved, a refusal letter will be sent to the client.

We are currently are not taking requests for ramps from the following counties: 

Clay, Delaware, Elkhart, Howard, Lake and Vigo.

SAWs also does not serve the following counties due to an existing group in that area: 

Allen, Adam, Clark and  Floyd

Date/Time*
Will the Referring Partner Agency fund the ramp?*
Referring Org - Agent Name*
Please capture their phone number
Referring Partner - Has address changed?*

Referring Partner Organization - Change of Address

Complete this section if the Referring Partner Agency address has changed.

Referring Partner Organization Address*

Individual Requiring Assistance - Name, Address, Phone

Individual - Name*
Individual - Address*
Individual - Primary Phone Type*
Individual - Location of ramp - State *
Indiana Counties*
If county your trying to select is not on the list, please see list at top of form.
Email for workflow assignment by Affiliate.

Individual Requiring Assistance - Other Info

To be completed by Interview team

Do they have an alternative number on which they can be reached?
Individual - Have email*
Do they have an e-mail account
Please capture their email address
Individual - Gender*
Residence Type*
Rent or Own*
Do they own their residence?
Caretaker or Other Contact Name

Landlord

Landlord - Name*
Landlord - Address*

Wheelchair

Wheelchair Type *
Wheelchair Width*

Interview Questions

Individual - Age Range at Time of Referral*
Individual - Race*
Individual - Military Status*
Describe the level of difficult they experience exiting their home*
Able to exit without assistance*
Fearful of being unable to exit in an emergency*
Have they missed important appointments*

Interview Questions - Household Income, Assets and Medical Expenses

$
$
$
$

Comments - Interview Evaluation

By Submitting this Agency Partner Ramp Referral Form, I am certifying on behalf of the submitting agency that  

1) the person for whom the ramp request is submitted has a recognized disability necessitating a ramp for access, and  

2) the [person/household] has an annual income of not more than 60% of area median income (AMI) in the county in which the residence at which the ramp is to be constructed is located. 

Validation

Person doing Validation*
Date of Validation*
Duplicate Phone Number Detected*
After you submit the form, if a duplicate is detected answer "Duplicate - no new ramp" or "Duplicate - new ramp will be built". Before doing this determine what the Affiliate policy is. Add to the interview comments how many ramps this client has received.
Copy and paste the Primary Phone number here. Affiliate policy on duplicate will determine what should be done. This field will not be shown if the decision is "Duplicate - new ramp will be built" or "Duplicate - no new ramp”.
Decision on status of project at Validation step*
Reason for closing project at Validation stage*
You may check more then 1 box. If "Other", please explain.
Client Status*
Client Priority*
Potential Funding Source*
External (Sponsors, Churches, Organizations, Schools, Team Build Program, etc for a specific ramp); Internal (Grants, Individual Donations, etc) Specify in Other if not listed.

If project is closed a Refusal Letter must be sent.

The workflow process will skip to Refusal Letter Required, Step #10.

Send Waiver and Permission

Waiver of Liability is for the client.

Permission is for landlord if a rental.

Person sending Waiver and Permission*
Date Permission and/or Waiver Sent*

Received Waiver

Upload and the file copy of the signed waiver. If waiver is not received the project will be closed.

You may go back 1 step to Send Waiver and Permission if waiver needs to be resent.

Person receiving and filing Waiver.*
Was Waiver Received?*
A "No" answer will skip to Send Refusal Letter step.
Date Waiver Received*
NOW No File Chosen
File uploads may not work on some mobile devices.
Upload a copy of the waiver. pdf or .doc format. Limit file size to 2mb.

Owned not Rented

Property is owned.

No Permission needed. Submit Form.

Received Permission

Please indicate whether the Permission from landlord was received, upload and file.

Person filing Permission*
Was Permission Received?*
A "No" answer will skip to the Refusal Letter Sent step.
Date permission was received.*
A "No" answer will close the project. Refusal letter required.
No File Chosen
File uploads may not work on some mobile devices.
Please upload the signed Permission. Limit file size to 2mb.

Site Evaluation

Please enter the date that the site evaluation was completed, and attach file(s).

Person doing Site Evaluation
2nd Person doing Site Evaluation
Date Site Evaluation Completed
OK to proceed - Site Evaluation?*
"No" will close the project. A Refusal Letter required.
Not OK to proceed reason code - SAWs*
Not OK to proceed reason code - Client
Building Permit required
No File Chosen
File uploads may not work on some mobile devices.
Please upload the Sit Evaluation Form. Limit file size to 2 mb. If not used upload a blank .pdf file as this is a required field.
No File Chosen
File uploads may not work on some mobile devices.
Please upload sketch. Limit file size to 2mb.
Estimated total feet of Ramps + Platforms (whole number)
How many pictures to upload? (5 maximum)*
Limit picture size too 2mb. Large size pictures will exceed form capacity.
No File Chosen
File uploads may not work on some mobile devices.
Limit picture size too 2mb. Large size pictures may exceed form capacity.
No File Chosen
File uploads may not work on some mobile devices.
Limit picture size too 2mb. Large size pictures may exceed form capacity.
No File Chosen
File uploads may not work on some mobile devices.
Limit picture size too 2mb. Large size pictures may exceed form capacity.
No File Chosen
File uploads may not work on some mobile devices.
Limit picture size too 2mb. Large size pictures may exceed form capacity.
No File Chosen
File uploads may not work on some mobile devices.
Limit picture size too 2mb. Large size pictures may exceed form capacity.

Building Permit Received and Filed

Person receiving and filing Building Permit*
No File Chosen
File uploads may not work on some mobile devices.
Limit file size to 2 mb. Large size file may exceed form capacity.
Building Permit uploaded and filed*

Drawings

Please enter the date of drawing(s) completion and attach file(s).

Section will not allow data entry if closed during Validation, Waiver Received or Site Evaluation Steps.

Person doing drawing*
Date Drawing(s) Completed*
No File Chosen
File uploads may not work on some mobile devices.
Limit file size to 2 mb. Large size files may exceed form capacity.
No File Chosen
File uploads may not work on some mobile devices.
Limit file size to 2 mb. Large size files may exceed form capacity.
No File Chosen
File uploads may not work on some mobile devices.
Limit file size to 2 mb. Large size files may exceed form capacity. A material list may be added at the Build Step if not added here.

Scheduling - Prefabrication

Please enter the scheduled date of prefabrication.

Person doing Scheduling*
Scheduled Date - Prefabrication*

Scheduling - Installation

Please enter the scheduled date/time of Installation.

Scheduled Date - Installation*

Build Step

Project Manager*
Ramp built*
For a weather delay, select the “Go back to previous step” at the bottom of the form For a variety of reason SAWs may not build the ramp even though all the other process steps have been completed. If not built and not a weather delay, fill in reason below in comments. You may still upload a drawing and material list if not done in previous steps.
Actual Build Date*
Number between 1 - 20
No File Chosen
File uploads may not work on some mobile devices.
Limit picture size to 2 mb. Large size pictures may exceed form capacity.
No File Chosen
File uploads may not work on some mobile devices.
Limit picture size to 2 mb. Large size pictures may exceed form capacity.
No File Chosen
File uploads may not work on some mobile devices.
Limit picture size to 2 mb. Large size pictures may exceed form capacity.
No File Chosen
File uploads may not work on some mobile devices.
Upload Material List here if not uploaded during drawing step. Limit file size to 2 mb. Large size files may exceed form capacity.
No File Chosen
File uploads may not work on some mobile devices.
Upload Material List here if not uploaded during drawing step. Limit file size to 2 mb. Large size files may exceed form capacity.
Was ramp Finished during build?*
Ramp cost from the Material List
If ramp will not be built, describe why here. If ramp was built and not Finished, add any note here for the Finishing Crew.

Project Closed - Refusal Letter Sent

This Project Was Closed in a Previous Step.

Enter date refusal letter was sent and upload form.

Submission will be completed when form submitted.

Person sending Refusal Letter*
Refusal Letter Sent*
Used for workflow step logic
Date Refusal Letter Sent*
NOW No File Chosen
File uploads may not work on some mobile devices.
Limit file size to 2 mb. Large size files may exceed form capacity.
Short reason why letter not required

Finishing - Project Complete

Please enter date project Finished and/or Completed.

Finishing Crew Leader*
Date Finished*
Only add comments that add value to the history of the ramp. No client or volunteer confidential information.

Comments - Site Evaluation to Completion

No client confidential information.

Powered by Formstack Create your own form