Download Hearing Referral Form DHS 112B 2/08

Office of Administrative Hearings
FOR OAH USE ONLY
Date
Recv’d.:
Assigned Case No.:
Hearing Referral Form (Child Welfare Payments)
(Instructions are on page 2)
Required Case Information
Agency Name: Department of Human Services
Referral Date:
Hearing Request Rec’d Date:
Date of document or action from which hearing is requested:
DHS Case No:
Case Type:
Has this case been previously referred?
Yes
No
If yes, complete only the items that need changing or updating since your previous referral.
Identify the following:
1. Child requesting hearing:
Name:
Address:
Address:
City/State/Zip:
Phone:
Fax:
3. DHS representative for hearing:
Name:
Address:
Address:
City/State/Zip:
Phone:
Fax:
2. Representative of Child:
Name:
Address:
Address:
City/State/Zip:
Phone:
Fax:
4. DHS contact (if different from question 3.)
Name:
Address:
Address:
City/State/Zip:
Phone:
Fax:
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DHS 1122Bcwr (09/09)
5.
Is a pre-hearing conference necessary?
Yes
scheduling preferences, requirements or restrictions.
No. If yes, give date and time
6. What is the expected length of the hearing?
7. Does hearing need to be held in person?
8. Will an interpreter be required at hearing?
9. DOES THIS CASE REQUIRE:
IF
Yes
Yes
PROPOSED ORDER1
No
No If yes, the language:
PROPOSED AND FINAL ORDER2
FINAL ORDER
YOU HAVE OR OBTAIN INFORMATION, THAT ANYONE PARTICIPATING IN THE HEARING OF THIS CASE MAY PRESENT
A DANGER OR MAY BE A THREAT TO ANYONE ELSE INVOLVED IN THE HEARING, YOU MUST TELL THE
ADMINISTRATIVE LAW JUDGE, DHS,
AND THE PARTIES OR THEIR REPRESENTATIVE OF THE POTENTIAL DANGER
IMMEDIATELY.
INSTRUCTIONS:
This is the Office of Administrative Hearings’ referral form. This form, together with the required
documents3, is to be completed and sent to PO Box 14020, Salem, OR 97309-4020 every time you
1
This is the Administrative Law Judge's Proposed Order. If the Proposed Order is adverse to the claimant, the claimant has the right
to file written exceptions and argument to be considered by DHS in issuing the Final Order. Your exceptions and argument must be
received by DHS by the 10th day from the date of service. (OAR 413-010-0535(2)) Send them to:
Department of Human Services
Children, Adults and Families
Hearings and Rules Unit/Robert Trachtenberg
500 Summer St. NE, E48
Salem, OR 97301
DHS will issue a Final Order that will explain your appeal rights.
2
This is the Administrative Law Judge's Proposed and Final Order. If the claimant does not submit timely written exceptions or
argument following a proposed and final order, the proposed and final order becomes a final order unless the Department has issued a
revised order or notice of reconsideration. You have the right to file written exceptions and argument to be considered by DHS in
issuing the Final Order. Your exceptions and argument must be received by DHS by the 10th day from the date of service. (OAR 413010-0535(2)) Send them to:
Department of Human Services
Children, Adults and Families
Hearings and Rules Unit/Robert Trachtenberg
500 Summer St. NE, E48
Salem, OR 97301
Required Documents are: A copy of the DHS contested case notice; a copy of request for hearing; copies of motions or
petitions filed with DHS; and any orders issued by DHS in the contested case. See OAR 137-003-0515(2).
3
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DHS 1122Bcwr (09/09)
wish to refer a case for hearing. OAH will use the information both for scheduling cases and for
collecting statistical data.
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DHS 1122Bcwr (09/09)