NOTICE OF ADDENDUM TO PROGRAM DESCRIPTION

This cover sheet must accompany each addendum

Addendum submitted for:

Residential Supported Employment/Day Services Family Support Other Services

Date:

Agency:

Agency Contact:

Phone	Fax	Email

Program VID#:

Program Address:

Purpose: The addendum is an official request to alter any component of the Program Description. Since change may result in a significantly different program than originally described, and given the potential to impact on the health, safety, welfare, and rights of the individuals receiving service, approval of a change is required prior to its implementation. Pertinent parties will be consulted regarding the proposed change. If there is any question as to whether an addendum is in fact required in a particular situation, please contact your Program Developer, Adult Services Coordinator or Family Support Administrator as appropriate.

The following information must be thoroughly supplied to address the reason for the addendum request:

1. Change: Indicate the specific section(s) of the Program Description being changed

and specify the change.

2. Rationale: Specify the reason for the change and indicate expected outcomes.

3. Attached related documents as required: Please use the same order as the original

document.

4. For residential program changes only, list the case managers for the individuals in this

program and give contact numbers.

5. Please attach all applicable documents.

Submitted by:	Signature:_____________________ Title:

FOR DDD USE ONLY:

APPROVED BY: DATE:

5/23/05

PROGRAM DESCRIPTION – NOTICE OF ADDENDUM

Authorized User

2009-07-29

NJ Dept. of Human Services

DHS