Hennepin County Human Services and Public Health Department
Eligibility and Work Services
MFIP Employment Services – MSTED Referral Form
(MN Subsidized and Transitional Employment Demonstration)
MFIP Counselor must email MSTED referral form to HSTED@Hennepin.us
REFERRING MFIP AGENCY
Referral date:
Referring agency:
Click here to enter a date.
Click here to enter text.
Selected MSTED agency:
Orientation date:
Choose an item.
Click here to enter a date.
Counselor name:
Counselor phone:
Click here to enter text.
Click here to enter text.
Counselor email:
Counselor fax:
Click here to enter text.
Click here to enter text.
Re-referral: ☐ No ☐Yes If Yes, re-referral reason:
☐Referred to MSTED but did not attended Orientation
☐Exited MFIP, later re-enrolled in MFIP with unused subsidized work weeks remaining
☐Assigned to treatment group but never entered subsidy - MFIP never closed
PARTICIPANT INFORMATION
Last name: Click here to enter text.
First name: Click here to enter text.
Street address:
Click here to enter text.
Phone (1): Click here to enter text.
Phone (2): Click here to enter text.
Case #:
Click here to enter text.
City:
Click here to enter text.
Language spoken:
Click here to enter text.
WF1 ID:
Click here to enter text.
Zip
Click here to enter text.
Interpreter needed?
☐No
☐Yes
ADDITIONAL INFORMATION: These items do not impact eligibility but help ensure quality services
Transportation available:
☐Bus ☐Car
☐Other Click here to enter text.
Criminal history:
Click here to enter text.
Hours required per week for
STED activity on EP:
Click here to enter text.
Domestic violence/safety
concerns:
Click here to enter text.
Mental health concerns:
Click here to enter text.
Job interest:
1 Click here to enter text.
2 Click here to enter text.
3 Click here to enter text.
Work limitations:
Click here to enter text.
Education level:
Click here to enter text.
Skills/certificates/diploma/degree:
Click here to enter text.
Comments: Additional information from referring MFIP agency
Click here to enter text.
Participant must be on current list in referral month
Be sure to update WF1 BEFORE emailing referral to HCC at HSTED@Hennepin.us
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Hennepin County Human Services and Public Health Department
Eligibility and Work Services
MSTED Employment Services Referral Checklist
This checklist is a tool to assist MSTED employment counselors in providing participants all necessary
information regarding the MSTED study. Please complete as you go through the referral process and
place in participant’s hard case file.
Date: Click here to enter text.
Participant name: Click here to enter text.
MFIP agency: Click here to enter text.
☐No show
Orientation date: Click here to enter a date.
Case number: Click here to enter text.
MFIP counselor: Click here to enter text.
Rescheduled date: Click here to enter a date.
Prior to Orientation
☐Followed up with participant regarding upcoming MSTED Orientation
During Orientation
☐Explained MSTED program in its entirety
Ensure participant completed:
☐ Informed consent form
☐ Contact form
☐ Background form
Participant attended MSTED Orientation
☐ Accepted random assignment
☐ Declined random assignment
☐ Emailed MFIP counselor that participant declined participation in random assignment
Participant assigned to Control Group
Inform participant:
☐ They will continue working with MFIP counselor
☐ Other services and community resources available to assist in job search
☐ They will continue to be part of the study
☐ They will get a gift card at the end of this interview
☐ MDRC will send them a follow-up survey, and when they complete it they will get another gift card.
Participant assigned to Treatment Group
☐ Scheduled meeting with participant to begin job placement process
End of Orientation (within 24-48 business hours)
☐ Emailed MFIP counselor, MSTED program manager and HCC no show and random assignment results
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Participant No Show for Initial Orientation
☐ Contacted participant to reschedule
☐ Emailed MFIP counselor of no show, reason for no show if provided, and rescheduled date if
applicable
Participant No Show for 2nd scheduled MSTED Orientation
☐ Emailed MFIP counselor status of No Show
Assigned as Secondary Worker WF1 updates
Control Group:
☐ Opened and closed service model in WF1
☐ Updated support services if applicable
☐ Add case note
☐ End MSTED assignment
Assigned as Secondary Worker WF1 updates cont’d
Treatment Group
☐ Open Service model assignment
☐ Open appropriate activity
☐ Add case note
Re-Referral Checklist
Participant exited MFIP, later re-enrolled in MFIP with
unused subsidized work weeks remaining
☐ Opened service model assignment
☐ Opened appropriate activity
☐ Add case note
Participant was assigned to treatment group but never entered subsidized
opportunity – MFIP never closed
☐ Opened service model assignment
☐ Opened appropriate activity
☐ Add case note
Updates and/or contact for all MSTED referral actions must be completed within 24-48 hours of
information received or requested.
Email questions to: HSTED@Hennepin.us
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