# AI-Generated Form # Not affiliated with, endorsed by, or derived from any form platform # This form was created by AI using only public survey topic metadata # (title + industry/category) as inspiration. It is an original adaptation # and does not copy, extract, or use proprietary content from Jotform, # Google Forms, ODK Collect, Tally, Formbricks, Cloudflare, or any other # form creation, data collection, or survey platform. # Released under CC BY 4.0. You are free to use, modify, and even sell # forms derived from it - just give credit. # Contact: form@gic.mx inputSchema: type: object properties: title: Assistance Checklist pages: - id: 1 name: checklist_date label: Checklist Date hint: Date of checklist type: date options: [] required: true - id: 2 name: client_name label: Client Name hint: Person receiving help type: text options: [] required: true - id: 3 name: client_id label: Client ID hint: Case or account number type: text options: [] required: true - id: 4 name: case_manager label: Case Manager Name hint: Who is assisting type: text options: [] required: true - id: 5 name: organization label: Organization hint: Agency name type: text options: [] required: true - id: 6 name: service_type label: Service Type hint: Category of assistance type: select_one options: - Financial Assistance - Housing Support - Employment Services - Healthcare Navigation - Food Assistance - Transportation - Childcare - Legal Aid - Counseling - Other required: true - id: 7 name: assistance_category_1 label: Assistance Category 1 hint: First area type: text options: [] required: true - id: 8 name: assistance_item_1a label: Item 1a hint: Specific task type: text options: [] required: true - id: 9 name: item_1a_status label: Item 1a Status hint: Complete or not type: select_one options: - Completed - In Progress - Not Started - Not Applicable required: true - id: 10 name: item_1a_date label: Item 1a Date hint: When done or due type: date options: [] required: false - id: 11 name: item_1a_notes label: Item 1a Notes hint: Comments type: text options: [] required: false - id: 12 name: assistance_item_1b label: Item 1b hint: Specific task type: text options: [] required: true - id: 13 name: item_1b_status label: Item 1b Status hint: Complete or not type: select_one options: - Completed - In Progress - Not Started - Not Applicable required: true - id: 14 name: item_1b_date label: Item 1b Date hint: When done or due type: date options: [] required: false - id: 15 name: item_1b_notes label: Item 1b Notes hint: Comments type: text options: [] required: false - id: 16 name: assistance_item_1c label: Item 1c hint: Specific task type: text options: [] required: true - id: 17 name: item_1c_status label: Item 1c Status hint: Complete or not type: select_one options: - Completed - In Progress - Not Started - Not Applicable required: true - id: 18 name: item_1c_date label: Item 1c Date hint: When done or due type: date options: [] required: false - id: 19 name: item_1c_notes label: Item 1c Notes hint: Comments type: text options: [] required: false - id: 20 name: assistance_category_2 label: Assistance Category 2 hint: Second area type: text options: [] required: true - id: 21 name: assistance_item_2a label: Item 2a hint: Specific task type: text options: [] required: true - id: 22 name: item_2a_status label: Item 2a Status hint: Complete or not type: select_one options: - Completed - In Progress - Not Started - Not Applicable required: true - id: 23 name: item_2a_date label: Item 2a Date hint: When done or due type: date options: [] required: false - id: 24 name: item_2a_notes label: Item 2a Notes hint: Comments type: text options: [] required: false - id: 25 name: assistance_item_2b label: Item 2b hint: Specific task type: text options: [] required: true - id: 26 name: item_2b_status label: Item 2b Status hint: Complete or not type: select_one options: - Completed - In Progress - Not Started - Not Applicable required: true - id: 27 name: item_2b_date label: Item 2b Date hint: When done or due type: date options: [] required: false - id: 28 name: item_2b_notes label: Item 2b Notes hint: Comments type: text options: [] required: false - id: 29 name: assistance_item_2c label: Item 2c hint: Specific task type: text options: [] required: true - id: 30 name: item_2c_status label: Item 2c Status hint: Complete or not type: select_one options: - Completed - In Progress - Not Started - Not Applicable required: true - id: 31 name: item_2c_date label: Item 2c Date hint: When done or due type: date options: [] required: false - id: 32 name: item_2c_notes label: Item 2c Notes hint: Comments type: text options: [] required: false - id: 33 name: overall_progress label: Overall Progress hint: How things going type: select_one options: - Excellent - On Track - Good - Minor Delays - Fair - Some Challenges - Poor - Significant Barriers required: true - id: 34 name: barriers_identified label: Barriers Identified hint: What is blocking type: text options: [] required: false - id: 35 name: next_steps label: Next Steps hint: What comes next type: text options: [] required: true - id: 36 name: follow_up_date label: Follow-up Date hint: When to check in type: date options: [] required: true - id: 37 name: client_signature label: Client Signature hint: Type name to acknowledge type: text options: [] required: true - id: 38 name: case_manager_signature label: Case Manager Signature hint: Type name to sign type: text options: [] required: true