Monitoring Technology Approval Request (DHS-6789A)

Lead agencies only need to complete and submit this form to DHS when requesting to use a video camera in a participant’s bedroom. For more information on usage and policy, see CBSM — Monitoring technology usage.

The lead agency must receive approval from the DHS monitoring technology review panel to use a camera and video equipment in a person’s bedroom. The use of any type of monitoring technology must include assurances of informed choice (via an informed consent process), data security, health and individual safety handled and approved by the lead agency.

Information (to be completed by case manager)

Participant

Participant name

PMI

Date of birth (MM/DD/YYYY)

County of residence

Today's date (MM/DD/YYYY)

Is the participant a minor child living with parent or legal guardian?

Yes

Do you request an expedited review (within 3 working days) vs. the standard timeframe of fewer than 10 days?

Yes

If yes, what is the reason?

Monitoring Technology Approval Request (DHS-6789A)

Information (to be completed by case manager)Participant

Information (to be completed by case manager)

Participant