Form 5 08272014 NH
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ABCDEFGHIJKLMNOPQRSTUVWXYZAAABACADAEAFAGAHAIAJAKALAMANAOAPAQ
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Registration:
New
or
Update
NFCSP/Statewide Respite
Includes Service Data
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(Caregivers complete sections I, II, IV, V, Via, Vib, IX)
(Complete section IX)
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I. SAMS Details - Personal
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a.) Consumer Name
First:
Last:
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b.) Current Date
//
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c.) Marital Status
Divorced
Legally Separated
Married
Single
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Widowed
Civil Union
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d.) Gender
Female
Male
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e.) Birth Date
//f.)
SSN (SOCIAL SECURTIY) : 000-00-
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g.) Default Agency
Senior Resources
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II. SAMS Details - Residential Address
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a.) Street 1
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b.) Street 2
c.) Phone:
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d.) Town, Zip Code
Town:
State (if not CT):
Zip Code:
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III. SAMS Details - Characteristics
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a.) Cognitive
Has Alzheimer's disease or a related dementia.
If Known
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Impairment
Yes (mild)
No (none)
Unkown
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b.) Meal Eligibility
Age 60 and Older
Disabled in Elderly Housing with Meal Site
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Type
Spouse
Disabled Living with Elderly Person
Volunteer
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IV. SAMS Details - Care Enrollment/Provider
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a.) Care Enrollment
Level of Care:
Service/Care Program:
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b.) Provider Name
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Your agency
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V. SAMS Details - Caregiver/Care Recipient (only for NFCSP and CT Statewide Respite Care)
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a.) Care Status
Care Recipient
Name of Caregiver:
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Caregiver
Name of Care Recipient:
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b.) Relationship
Daughter
Daughter-in-Law
Grandparent
Husband
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Non-Relative
Other Elderly Non-Relative
Other Elderly Relative
Other Relative
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Relationship Missing
Son
Son-in-Law
Wife
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VI Assessment Form - Demographics
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a.) Ethnicity
Hispanic/Latino
Not Hispanic/Latino
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b.) Race
Native American/Alaska Native
Asian
Black/African American
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(Check all that apply)
Native Hawaiian/Pacific Islander
Non-Minority, White Non-Hispanic
Other
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White, Hispanic
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c.) Housing
Private Home
Private Apartment
Senior Housing
Congregate Housing
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Public Housing
Residential Care Home
Assisted Living
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Other
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if "other" is checked enter type of housing
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VI Assessment Form - Demographics (Continued)
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d.) Income
I live alone and my monthly income is about:
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(1/24/2006)
Under $958 (100%)
$959 - $1,197 (125%)
$1,198- $1,436 (150%)
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If living with someone other than spouse, use "I live alone…" section at top
$1,437 - $1,676 (175%)
$1,677 - $1,915 (200%)
$1,916 or over (over 200%)
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I live with my spouse and our monthly income is about:
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Under $1,293 (100%)
$1,294 - $1,616 (125%)
$1,617 - $1,939 (150%)
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$1,940 - $2,262 (175%)
$2,263 - $2,585 (200%)
$2,586 or over (over 200%)
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e.) In Poverty
Yes
No
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f.) Living Arrangements
Alone
With Spouse/Partner
With Spouse and Child/Children
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With Child, No Spouse
With Other Relatives
With Others
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VII Assessment Form - Functional Status
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a.) ADL/IADL
I need help with these activities
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On each line enter: Y for yes, N for no
Eating
Dressing
Bathing/Washing
Using the Toilet
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Getting Out of Bed/Chair
Walking
Planning/Preparing Meals
Shopping
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Managing Money
Using the Telephone
Heavy Housework
Light Housework
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Taking Medicine
Using Transportation
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VIII. Assessment Form - Nutrition
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a.) Nutritional Risk
Yes
No
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For Consumers Receiving: case management, congregate meals, home-delivered meals, nutritional counseling
I have an illness or condition tht made me change the kind or amount of food I eat. (2)
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Form 5