Fillable State Caregiver Assessments (PDF, 5.87MB) (Administration for Community Living)

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State Caregiver Assessments (PDF, 5.87MB) (Administration for Community Living)

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SUA Resource Library:
State Caregiver Assessments
Foreword
In 2012, the Administration for Community Living (ACL), an operating division of the US
Department of Health and Human Services, began a comprehensive evaluation of its National
Family Caregiver Support Program (NFCSP). This was the first comprehensive federal evaluation
of the NFCSP, which serves over 800,000 family caregivers annually. The NFCSP evaluation has
three broad goals to benefit policy and program decision-making:
1. Collect and analyze information on program processes and site operations;
2. Evaluate program efficiency and cost issues for approaches best suited to specific
contexts; and
3. Evaluate effectiveness of the program’s contribution to family caregivers in terms of
maintaining their health and well-being, improving their caregiving skills, and
avoiding or delaying institutional care of the care recipient.
As part of the evaluation survey, State Units on Aging (SUAs) were asked to submit relevant
documents if they answered ‘yes’ to any of the following five questions:
Do you have a statewide task force, commission or coalition specifically to examine
family caregiver issues?
Have community needs assessments for caregiver support services been conducted?
Does your state have a standardized caregiver assessment?
Does your SUA conduct routine programmatic monitoring of the NFCSP program?
Do you use a uniform caregiver satisfaction survey across all AAAs?
ACL received assessment tools and grouped them into the following categories:
1. Community Assessment Materials
2. General Customer Satisfaction Survey Materials
3. Grandparent Assessment Materials
4. High-Level Administrative Materials
5. Program Monitoring Materials
6. State Caregiver Assessments
7. State Care Recipient Assessments
8. Task Force Materials
9. Uniform Satisfaction Materials
10. Other Materials
While ACL does not specifically endorse these tools, we are sharing them because they may be
helpful to other programs. For more information on the NFCSP please go to:
http://www.aoa.acl.gov/. For more information on the evaluation of the NFCSP please go to:
http://www.aoa.acl.gov/Program_Results/Program_Evaluation.aspx
State Caregiver Assessments
Delaware CareGIVER Assessment ................................................................................................................. 3
District of Columbia Caregiver Assessment – Reassessment ...................................................................... 4
District of Columbia Caregiver Assessment for SSN Case Managers ......................................................... 11
Kansas III-E Caregiver Assessment Plan ..................................................................................................... 20
Louisiana Instructions and Intake Assessment Form ................................................................................. 24
Massachusetts Caregiver Assessment Tool 2015 ....................................................................................... 36
Minnesota Title III-E Caregiver Questionnaire ........................................................................................... 45
New Hampshire Initial Caregiver Assessment ........................................................................................... 55
Ohio Caregiver Assessment ........................................................................................................................ 61
Rhode Island Long Term Services and Supports Caregiver Assessment ..................................................... 65
South Carolina Eligibility for Title III-E Services Assessment....................................................................... 67
South Dakota Caregiver Assessment .......................................................................................................... 71
Tennessee Caregiver Assessment Instructions ........................................................................................... 75
Tennessee Caregiver Assessment ............................................................................................................... 79
Utah Caregiver Assessment Form ............................................................................................................... 84
Utah Caregiver Intake Form ........................................................................................................................ 94
Virginia Uniform Assessment Instrument ................................................................................................... 98
Vermont DAIL Independent Living Assessment ........................................................................................ 110
Wyoming Caregiver Evaluation ................................................................................................................. 139
2
3
Delaware CareGIVER Assessment
DC
OA
CG Assessment Form 7
-14-10
1
DC OF
FICE O
N A
GING
CAREGIVER ASSESS
MENT- REASSESSMENT
Primary Caregiver Profile
Date: ____________ Caregiver for how long? __________
Social Security #_________________________ Date of Birth :_________________
CG I.D. No.__________________ Referral Source_______________________
Caregiver Name: ______________________, ____________________, __________
(last) (first) (mi.)
Address & Zip: _________________________________________________________
Daytime Phone: ____________________ Evening Phone__________________
Emergency Contact for Caregiver: _________________________________________
Your relationship to Care Receiver:
[ ] spouse [ ] sibling [ ] child [ ] friend/neighbor [ ] step child [ ] other _____________
Do
yo
u co
nsider your caregiving respon
sibilities to be?
[ ] 24 hours [ ] full time [ ] part time [ ] occasional
ADL and IADL needs that you or others provide to the care receiver:
T
ask
No
h
elp
A
ssist
T
ota
l
Care
T
ask
No
h
elp
S
up
e
r-
v
ise
A
ssist
T
ota
l
Care
B
ath
ing
S
ho
pp
ing
Groo
mi
ng
Cl
ea
ning
E
atin
g
T
rans
-
p
ortat
ion
T
oil
eti
ng
Y
ard
Wo
rk
M
ob
ility
B
ill Pa
ying
W
a
l
king
Hea
v
y
Cl
ea
ning
T
rans
fer-
ri
ng
M
ed
ication
s
M
an
ag
ement
Dr
ess
ing
Use
of
T
ele
ph
one
T
he
rapy
/
E
xe
rcise
E
scort
M
ea
ls
M
ed
ical
A
pp
ts
L
au
ndry
Coo
rdinat
e
S
erv
ices
4
District of Columbia Caregiver Assessment – Reassessment
DC
OA CG Assessment Form 7
-14-10
2
Do
yo
u a
lso provide care for someo
ne else? [ ] Yes [ ] No
If yes, describe your other caregiving responsibility______________________________________
What is your employment status?
[ ] full time [ ] leave of absence
[ ] part time [ ] retired
[ ] short term disability [ ] unemployed
[ ]
long
term disability [ ] n
ot able to work due to care for CR
Informa
l S
upport
How
w
ou
ld you describe your social support system? (READ LIST - check ONE that best describes)
[ ] excellent, includes willing family members and friends
[ ] good, includes family members and friends
[ ] fair, minimal support from family or friends
[
] poo
r, no willing family m
embers or friends
Who helps you provide care?
Name Relationship to Caregiver Assistance Provided
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Are there others who could assist you (family, friends, neighbors, club members, volunteers from a
religious institution) [ ] Yes [ ] No
List other potential caregivers:
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Liv
ing A
rrangem
ents
Caregiver’s living arra
ngement/setting:
[ ] lives with Care Receiver in Washington, DC
[ ] lives in Washington, DC apart from Care Receiver distance between homes:___________
[ ] drive [ ] walk [ ] public transportation [ ] other__________
Who are the members of your household?
Name Age Gender Relationship
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_
____
______________
___________________________________________________________
Hea
lth/Mental Health
Would you descri
be your health as:
[ ] excellent [ ] good [ ] fair [ ] poor
5
District of Columbia Caregiver Assessment – Reassessment
DC
OA
CG Assessment Form 7
-14-10
3
Do
yo
u h
ave any medical conditions
or physical limitations? [ ] Yes [ ] No (LIST ALL)
How do you describe your emotional health?
[ ] excellent [ ] good [ ] fair [ ] poor
Rece
ntly
, h
ave you experience
d any changes in your physical or emotional health?
[ ] Yes [ ] No If yes, describe:
________________________________________________________________________
________________________________________________________________________
What concerns, if any, do you have about your physical or emotional health?
________________________________________________________________________
_________________________________________________________________________
S
tress
A
re yo
u currently experiencing
stress because of your caregiving role [ ] Yes [ ] No
If yes, what exactly about your caregiving responsibilities is stressful?
Caregiver self-report stress level: (circle which applies)
0 1 2 3 4 5 6 7 8 9 10
no stress maximum stress
(I can’t continue giving care)
What is the most stressful aspect of caregiving for you?
Are you experiencing stress in other areas of your life related to: (READ LIST, Mark ALL that apply)
[ ] children [ ] work [ ] marriage
[ ]
pe
rsonal health concerns
[ ] legal arrangements regarding care receiver (power of
[ ] family attorney, advice directives, wills)
[ ] other: _________________________________________________________________
Cop
ing
Describe
your social outlets, leisure activities, and civic and religious involvement (and how often
these occur):
How do you manage all your responsibilities?
What is working well in your caregiving situation?
6
District of Columbia Caregiver Assessment – Reassessment
DC
OA CG Assessment Form 7
-14-10
4
On
e i
mp
ortant lesson you ha
ve learned and can recommend to other caregivers?
Res
ource
Utiliza
tion
Have you used community
resources to help YOU? [ ] Yes [ ] No (If no, skip next question)
What are the community resources you currently use?
[ ] Homecare [ ] adult daycare [ ] Caregiver educational program
[
] Writt
en resource materials [
] other______________________________________
[ ] Respite care – Name of Provider ___________________________________________
[ ] Caregiver support group -Name of sponsor __________________________________
Why haven’t you used community resources for caregivers?
[ ] Did not know about them [ ] Do not have the time [ ]Other_________________
[ ] Financial barriers [ ] Transportation barriers
C
ARE
RECEIV
ER INFORMATION
The following q
uestions are about your older relative/friend:
Care Receiver Name: __________________, __________________, ______________
(last) (first) (mi.)
A
ddress: _
______________
___________________, Zip Code __________________
Ward______________ Phone: ___________________ Date of Birth _______________
Care Receiver’s Gross monthly income: $_____________ Source: ________________
Insurance:____________________________________________________________
Hea
lth/Me
nta
l Health Inventory
Description of ca
re receiver’s current health status, illnesses and disabilities:
A
lert:[ ]Y
es [ ]No Orien
ted to: [ ]Person [ ]Place [ ]Time Ambulatory: [ ]Yes [ ]No
Inco
ntin
en
ce: [ ]Bowel [ ]Bladd
er
Can
be lef
t alone Yes No Comment:
________________________________________
Description of care receiver’s emotional health:
What health issue causes you the greatest concern and why?
7
District of Columbia Caregiver Assessment – Reassessment
DC
OA
CG Assessment Form 7
-14-10
5
Res
ource
Utiliza
tion
What community resources d
oes the older person use and how often?
Service Provider Frequency
_________________________________________________________________________
_
__
__
______________
______________________________________________________
_________________________________________________________________________
Does the older person resist using services? [ ] No [ ] Yes, __________________________
Are there services, supplies or equipment you need for caregiving that you can not afford at this time?
[ ] Yes [ ] No
If yes, List below:
__________________________________________________________________________
__________________________________________________________________________
Other Comments/issues of concern/recommendations not addressed elsewhere in this assessment:
__________________________________________________________________________
__________________________________________________________________________
8
District of Columbia Caregiver Assessment – Reassessment
DCOA
C
G Assessment Form 7
-14-10
6
Careg
iv
er Support Plan
Caregi
ver Name ______________________ CG I.D. #_________________
Date________________________________
A. Self Care and Stress Management Recommendations (Mark ALL that apply)
[ ] 1 Participate in a caregivers’ support group
[ ] 2 Attend educational seminars
[ ] 3 Use respite care
[ ] 4 Get physical exam
[ ] 5 Start a fitness program (what type) _____________________________________________
[ ] 6 Participate in a hobby
[ ] 7 Learn and practice stress reduction techniques (how) _______________________________
[ ] 9 Let others help you
B. Informal Support Plan
For each recommendation checked in Section A, outline the way in which the recommendation can
be implemented. Be specific, listing the names and phone numbers of services to be accessed
(support groups, daycare programs, etc.) and identifying family members and friends who can provide
informal support and the type of support needed.
Service Agency Tel. #
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Informal Support – Describe how family members and friends will be involved in caregiving (i.e., the
name of the person, what assistance is needed, how to approach the person to obtain assistance,
etc.)
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
I un
de
rstand the elements o
f this support plan and am willing to implement the plan.
_________________________
__
_________ ________________________________________
Car
eg
iver Signature and
Date Assessor Signature and Date
9
District of Columbia Caregiver Assessment – Reassessment
DC
OA
CG Assessment Form 7
-14-10
7
P
ost vis
it comme
nts
Rate the potentia
l for Caregiver/situation to deteriorate in the next 12 months
0 1 2 3 4 5 6 7 8 9 10
will stay the same Moderate potential for decline High potential for situation to collapse
Do
yo
u t
hink the Care Receiver will u
se the services recommended today?
[
] Y
es
[ ] No
[ ] Yes, unde
r the following conditions____________________________
__________________________________________________________
Do
yo
u t
hink the Care Giver will f
ollow through with services recommended today?
[
] Y
es
[ ] No
[ ] Yes, unde
r the following conditions____________________________
_________________________________________________________
10
District of Columbia Caregiver Assessment – Reassessment
1
CA
S
E
MAN
AGER: ASSESSMENT DA
TE:
D.C. O
FFICE O
N
AGI
NG
C
A
REG
IVE
R ASSESSMENT
C
A
REG
IVE
R PROFILE
Ne
w
Cli
ent
Rea
s
s
es
sment
S
o
cial S
ecu
rity #.__________
______ Date of Birth__________________ __
Ref
e
rr
al So
urce_____________
__________ _
Care
g
i
ve
r Name: ___________
___________, ____________________, ____________
(la
st) (first)
(mi.)
A
d
d
ress: _
______________
________________________________ Zip Code__ __
P
h
o
ne
: Day ____________
__Evening_____________ Caregiver for how long?_____ _
E
m
e
rge
ncy Contact for Caregiver: ___
_______________________________________
Y
o
u
r Relation
ship to Care Receiver:
sp
o
use
child step child fri
end/neighbor sibling other ___
____
Do
y
o
u co
nside
r your caregiving respon
sibilities to be?
2
4
hours
full-time
part-time
occasional
A
D
L/I
AD
L ass
istance that you or others provide
to the care receiver:
T
a
sk
No
Help
Super
-vise
A
ssist
T
o
ta
l
Care
T
a
sk
No
Help
S
u
p
er
-vise
A
ssist
T
o
ta
l
Care
B
a
th
ing
S
h
o
pp
ing
Groo
m
i
ng
Cl
e
a
ning
E
a
tin
g
T
ran
s
po
r
-
tin
g
T
o
il
eti
ng
Y
a
rd
Wo
rk
M
o
b
ility
B
il
l Pa
ying
W
a
lking
Hea
v
y
Cl
e
a
ning
T
ran
s-
fe
rr
ing
M
e
d
ication
Mg
m
t
Dr
e
ssing
Use
o
f
T
e
le
ph
one
T
h
e
rapy
/
E
x
e
rcise
E
sco
rt
M
e
a
ls
M
e
d
ical
A
p
p
tm
ts
L
a
u
nd
ry
Coo
rdin
-
a
te
S
e
rv
Do
y
o
u a
lso provide care for someo
ne else? Yes No
11
District of Columbia Caregiver Assessment for SSN Case Managers
2
If
yes, d
escribe your other care
giving
responsibility ____________________________
W
hat is y
our employment st
atus
?
full
-time leave of
absence
pa
rt-time retired
sho
rt-term disability u
nemployed
long
-term
disability n
ot able to work due to care for CR
Informa
l Support
How
wou
ld you describe yo
ur social s
upport system? (READ LIST - check ONE that
b
est de
scribes)
ex
celle
nt, includes willing
family members and friends
go
od,
includes family mem
bers and friends
fair, minimal suppor
t from family or friends
po
or, no willing family
members or friends
W
ho h
elps you provide care?
Nam
e
Relationship to Caregiv
er
Assistance Provided
_
____
___________
___
____________________________________________
_
____
___________
___
____________________________________________
_
____
___________
___
____________________________________________
A
re there o
thers who could a
ssist you
(family, friends, neighbors, club members,
v
oluntee
rs from a religiou
s institu
tion) Yes No
L
ist othe
r potential caregive
rs:
_
____
___________
___
____________________________________________
_
____
___________
___
____________________________________________
Liv
ing Arrangem
ents
Care
give
r’s living arrangem
ent
/setting:
liv
es w
ith Care Receiver in Washing
ton, DC
live
s in Washington, DC apart
from Care Receiver
distan
ce between hom
es: _
_______________
drive walk p
ublic transportation
o
ther__
________
W
ho a
re the members o
f yo
ur household?
12
District of Columbia Caregiver Assessment for SSN Case Managers
3
Name
Age G
ender Relationship
__
___
___
___________
________________________________________________
__
___
______________
________________________________________________
__
___
___
___________
________________________________________________
Health/M
enta
l Health
Wo
uld
you describe your healt
h as:
ex
cellent good
fair poor
Do y
ou h
ave
any medical conditions
or physical limitations? Yes (LIST ALL) No
__
___
______________
_____________ ________________________________
__
___
___
___________
_____________ ________________________________
__
___
______________
_____________ ________________________________
How d
o yo
u describe your emotio
nal health?
ex
cellent good
fair poor
Recen
tly, h
ave
you experien
ced any changes in your physical or emotional health?
Ye
s No
If y
es, d
escribe:
__
___
___
___________
___________________________________________________
__
___
______________
___________________________________________________
Wh
at co
ncerns, if any, do yo
u have about your physical or emotional health?
__
___
___
___________
___________________________________________________
__
___
______________
___________________________________________________
Stres
s
Are y
ou cu
rren
tly experiencing stress
because of your caregiving role Yes No
If y
es, w
hat exactly about yo
ur caregiving responsibilities is stressful?
__
___
______________
___________________________________________________
__
___
___
___________
___________________________________________________
Ca
regiv
er self-report stress level: (circle w
hich applies)
13
District of Columbia Caregiver Assessment for SSN Case Managers
4
0 1 2 3 4 5 6 7 8 9 10
n
o stress
m
aximum stress
(I can
’t c
ontinue giving care)
W
hat is the most stressful a
spect o
f caregiving for you?
_
______________
____
___________________________________________________
_
______________
____
___________________________________________________
_
______________
____
___________________________________________________
A
re you experiencing stress in
othe
r areas of your life such as: (READ LIST, Mark ALL
th
at apply)
children legal arr
ang
ements regarding care receiver
marriage (i.e.,
pow
er of attorney, advance directives,
family wills)
personal health concerns
oth
er ____ _
work
Cop
ing
Describe
your social outlets, leisure activ
ities, and
civic and religious involvement (and
h
ow often these occur)
: ___
_______________________________________________
_
______________
____
___________________________________________________
_
______________
____
___________________________________________________
How
do you manage all y
our re
sponsibilities? _________________________________
_
______________
____
___________________________________________________
_
_______________
____
__________________________________________________
W
hat is working well in y
our careg
iving situation? ______________________________
_
______________
____
___________________________________________________
_
______________
____
___________________________________________________
On
e important lesson y
ou ha
ve learned and can recommend to other Caregivers?
_
______________
____
___________________________________________________
Res
ource Utilization
Hav
e you used community reso
urces to h
elp YOU? Yes No (Skip next Q.)
14
District of Columbia Caregiver Assessment for SSN Case Managers
5
Wh
at are the community reso
urces y
ou currently use?
Careg
iver support group
Nam
e of Support Group S
pon
sor______________________________________
Careg
iver educational program
Respite
care (i.e., day care, home
care)
Se
rvice/Provider__________
_________________________________________
Careg
iver Institute
Wri
tten resource materials
Oth
er_____________
___________________
Wh
y haven’t you used
com
munity resources for caregivers?
Did
not know about them
Do n
ot have the time
Finan
cial barriers
Tra
nsportation barriers
Oth
er_____________
___________________
CA
RE RECEIVER INFORMATION
Th
e following questions a
re abo
ut your older relative/friend:
Care Re
ceiver Name: _______
___
________, __________________, ______________
(last) (first)
(mi.)
Ad
dress: ____________
___
___________________, Zip Code ___________ _______
Wa
rd____________
__
Phone: ___________________ Date of Birth______ _____
Care Re
ceiver’s Gross monthly incom
e: $
_______________ Source______________
Insu
rance ___________
___
_______________________________________________
Health/M
ental Health Inventory
Description
of care receiver’s curren
t he
alth status, illnesses and disabilities:
AL
ERT Yes ORIENTED
P
erson AMBULATORY Yes
No Place
No
Time
CAN BE
LEFT ALONE Yes
INCONTINENCE
Bladder
No
Bowel
Comme
nts:
15
District of Columbia Caregiver Assessment for SSN Case Managers
6
Description
of ca
re receiver’s emotional h
ealth:
__
___
___
___________
___________________________________________________
Wh
at
health issues cause you t
he greatest concern and why?
__
___
___
___________
___________________________________________________
__
___
______________
___________________________________________________
Resourc
e Utiliza
tion
Wh
at co
mmunity resources does th
e older person use and how often?
Se
rvice
Provider Frequenc
y
__
___
______________
________________________________________________
__
___
___
___________
________________________________________________
__
___
______________
________________________________________________
Does t
he o
lder person resist using services?
Yes No
If y
es, w
hy? __________
_________________________________________________
__
___
______________
___________________________________________________
__
___
______________
___________________________________________________
Are t
here se
rvices, su
pplies or equipmen
t you need for yourself or the older person that
yo
u can
not afford at this tim
e? Yes No If yes, list below:
16
District of Columbia Caregiver Assessment for SSN Case Managers
7
__
______________
___
___________________________________________________
Oth
er Comments/issues of concern/r
ecom
mendations not addressed elsewhere in this
asse
ssment:
__
______________
___
___________________________________________________
CA
REGIVER SUPP
ORT PL
AN
A.
Self Care and Stress Manageme
nt Rec
ommendations (Mark ALL that apply)
1 A
ttend caregiving support g
roup
17
District of Columbia Caregiver Assessment for SSN Case Managers
8
2 A
ttend educational semin
ars
3
Use respite care
4 G
et physical exam
5
Start a fitness program
6 P
articipate in a hobby
7 A
ttend counseling
8 L
earn and practice stress red
uction techniques
9 L
et others help you
B. S
upport Plan
For ea
ch recommendation checked
in Se
ction A, outline the way in which the
recom
mendation can be im
ple
mented. Be specific, listing the names and phone
nu
mbers of services to
be a
ccessed (support groups, day care programs, etc.) and
iden
tifying family membe
rs and
friends who can provide informal support and the type
of
support needed.
Se
rvices Agency
Tel. #
__
______________
___
_______ ___________________________ ____________
__
______________
___
_______ ___________________________ ____________
__
______________
___
_______ ___________________________ ____________
__
______________
___
_______ ___________________________ ____________
__
______________
___
_______ ___________________________ ____________
Informal
Support – Describe how famil
y me
mbers and friends will be involved in
careg
iving (i.e., the name o
f th
e person, what assistance is needed, how to approach
the
person to obtain as
sistance
, etc.)
__
______________
___
___________________________________________________
__
______________
___
___________________________________________________
__
______________
___
___________________________________________________
__
______________
___
___________________________________________________
__
______________
___
___________________________________________________
18
District of Columbia Caregiver Assessment for SSN Case Managers
9
POS
T VISIT COMMENTS
Rate
the potential for th
e Careg
iver situation to deteriorate in the next 12 months
0
1 2 3 4 5 6 7
8
9 10
W
ill stay the sa
me
Moderate potential for decline Higher potential for situation to collapse
Do y
ou think the Care Receiver
will f
ollow through with services recommended today?
Yes
Yes, under the follo
wing conditions ______________________________________
__
______________
___
__________________________________________________
No
Do y
ou think the Caregiver will f
ollo
w through with services recommended today?
Yes
Yes, under the follo
wing conditions ______________________________________
__
______________
___
__________________________________________________
No
OoA
Caregiver Asse
ssm
ent Form 12-15-04
19
District of Columbia Caregiver Assessment for SSN Case Managers
K
ANS
AS DEP
ARTMENT FOR AGING AND DISABILIT
Y SERVICES
III-E
CAREG
IVER
AS
SE
SS
MENT PLAN
K
AMIS
ID #
K
DOA
F
orm SS-025 Revised 07/01/2
012(KDADS)
I. INT
AKE
I
nit
ial
I
ntervie
we
r
PSA
Da
te of
Ass
essm
ent
R
eass
essm
ent
II
.
C
AR
EG
IVER
C
AT
EG
ORY
C
areg
iv
er (Complete Sec
. I
II
, V, V
I
, and V
II
)
G
randpa
ren
t:
C
aring
for
child(ren) < 19 years of
age (Complete Sec. III, IV, and V
II)
C
aring
for
disabled adult(s) 19
-59
ye
ars of
age
(C
omple
te Sec
. II
I,
I
V,
VI,
and V
II)
II
I. CAR
EG
IVER INFORMATIO
N
Ma
le
Fem
ale
N
ame (
Firs
t, Middle, Last
)
DOB
SSN
Ethni
cit
y:
N
ot H
is
panic or Latino
H
ispa
ni
c or Latino
R
ace:
A
fr
ica
n American
H
ispa
ni
c
R
eport
ing
other race
A
mer
ica
n Indian/Alaska Native
N
ati
ve Haw
aiian/Pacific Islander
Whi
te
/N
on
-H
ispa
nic
A
sian
R
eport
in
g
2 or m
ore r
aces
A
ddres
s
C
it
y
C
ounty
Sta
te
Z
ip C
ode
U
rban
R
ural
H
ome Phone
Wor
k Phone
C
ell
Phone
IV. C
AR
EG
IVER for Child(ren) or Disab
led Adult(s):
N
umber
of chi
ldren cared for:
N
umber
of di
sabled adults cared for:
R
ela
ti
onship to Child(ren)/Di
sabled Adult(s)
Gr
andpar
ent
Elde
rl
y R
elative
Elde
rl
y N
on
-r
elat
iv
e
V
. CA
RE
GIVER for Adult
-
R
ela
ti
onship to Recipient
H
usband
Wi
fe
D
aught
er/
Daughter
-in-l
aw
Son/Son-in-l
aw
O
ther
Rel
ative
N
on
-r
elat
iv
e
V
I. ADU
LT
CARE RECIPIENT #1 INFORMAT
ION:
Q
uali
fyi
ng Care Recipient:
Seni
or
60 yea
rs or older
A
dult
w/
Alzheimer’s <60
D
isa
bl
ed Adult 19
-59
Ma
le
Fem
ale
N
ame (
Firs
t, Middle, Last)
DOB
R
ec
ipie
nt SSN
A
ddres
s
C
it
y
C
ounty
Sta
te
Z
ip C
ode
U
rban
R
ural
H
ome Phone
Wor
k Phone
C
ell
Phone
ADLS
IAD
LS
Bat
hi
ng
Wa
lk
ing
/Mobility
Me
al
Prepa
ration
U
se of
Tel
ephone
D
res
si
ng
Eat
ing
Shoppi
ng
Laundr
y/
Hou
sekeeping
T
oi
let
ing
Mone
y Ma
nag
ement
Me
di
cat
ion Mgmt/Treatment
Tra
nsf
er
Tra
nspor
ta
tion
VII. C
AR
EG
IVER SERVICE PLAN
R
ecip
ient
No
.
Ser
vi
ce
C
ode
Prov
ider
Nam
e
U
nit
s
Per
T
ot
al
U
nit
s
Sta
rt
D
ate
End
D
ate
Dis
char
ge
C
od
e
20
Kansas III-E Caregiver Assessment Plan
K
DO
A Form SS-025 (10/01/10)
VIII. ADULT CARE RECIPIENT #2:
C
AR
EG
IVER for Adult
- R
elat
ionsh
ip to Recipient:
H
usband
Wi
fe
D
aught
er/
Daughter
-in-l
aw
Son/Son-in-l
aw
O
ther
Rel
ative
N
on
-r
elat
iv
e
Q
uali
fyi
ng Care Recipient:
Seni
or
60 yea
rs or older
A
dult
w/
Alzheimer’s <60
D
isa
bl
ed
A
dul
t < 60
A
DU
LT
CARE RECIPIENT
#2 INF
OR
MATI
ON
Ma
le
Fem
ale
N
ame (
Firs
t, Middle, Last
DOB
R
ec
ipie
nt SSN
A
ddres
s
C
it
y
C
ounty
Sta
te
Z
ip
C
ode
U
rban
R
ural
H
ome Phone
Wor
k Phone
C
ell
Phone
ADLS
IAD
LS
B
ath
ing
Wa
lk
ing
/Mobility
Me
al
Pr
epar
ati
on
U
se of
Tel
ephone
D
res
si
ng
Eat
ing
Shoppi
ng
Laundr
y/
Hou
sekeeping
T
oi
let
ing
Mone
y Ma
nag
ement
Me
di
cat
ion Mgmt/Treatment
Tra
nsf
er
Tra
nspor
ta
tion
IX. AD
ULT CA
RE RECIP
IENT #3:
C
AR
EG
IVER for Adult
- R
elat
ionsh
ip to Recipient:
H
usband
Wi
fe
D
aught
er/
Daughter
-in-l
aw
Son/Son-in-l
aw
O
ther
Rel
ative
N
on
-r
elat
iv
e
Q
uali
fyi
ng Care Recipient:
Seni
or
60 yea
rs or older
A
dult
w/
Alzheimer’s <60
D
isa
bl
ed Adult < 60
A
DU
LT
CARE RECIPIENT #
3 INF
OR
MATI
ON
Ma
le
Fem
ale
N
ame (
Firs
t, Middle, Last
DOB
R
ec
ipie
nt SSN
A
ddres
s
C
it
y
C
ounty
Sta
te
Z
ip
C
ode
U
rban
R
ural
H
ome Phone
Wor
k Phone
C
ell
Phone
ADLS
IAD
LS
B
ath
ing
Wa
lk
ing
/Mobility
Me
al
Pr
epar
ati
on
U
se of
Tel
ephone
D
res
si
ng
Eat
ing
Shoppi
ng
Laundr
y/
Hou
sekeeping
T
oi
let
ing
Mone
y Ma
nag
ement
Me
di
cat
ion Mgmt/Treatment
Tra
nsf
er
Tra
nspor
ta
tion
X. NOTES:
21
Kansas III-E Caregiver Assessment Plan
KDO
A
Form SS-025 (10/01/10)
III-E CAREGIVER ASSESSMENT PLAN
INSTRUCTIONS
GENERAL
D
o not us
e thi
s form if you are providing “Information” or “Assistance” only.
C
ompl
ete t
he entire III-E Caregi
ver Assessment Plan (CAP) according to the instructions provided below when
requesting or providing the following Title III-E Services: Individual Counseling; Support Group; Caregiver
Training (Individual or Group); Respite; and Supplemental Services.
SECTION I: INTAKE
C
ompl
ete al
l information in Section I.
SE
C
T
ION
II: CAREGIVER CATEGO
RY
C
heck
the f
unding category for which t
he applicant is applying. If applying for more than one category, separate
forms must be completed.
C
heck
“Grandpar
ent” if caring for Chi
ld/Children < 19 years of age or disabled adult(s) 19 - 59 years of age,
regar
dles
s of
the caregiver’s rela
tionship to the child or disabled adult.
SECTION
III
: CAREGIVER INFORMATIO
N
C
ompl
ete al
l “Ca
regiver” informati
on, including a complete address and Urban/Rural designation.
T
he Ethn
ic
ity and Race categories re
flect Office of Management and Budget (OMB) requirements. Caregivers
are to be asked about their ethnicity and race as two separate questions. The Caregiver should be given the
opportunity for self-identification, and allowed to designate all categories that apply to them. The Ethnicity and
Race categories will be used for data collection purposes only.
SECTION IV: CAREGIVER FOR CHILD/CHILDREN <19 YEARS OF AGE OR DISABLED ADULT 19-59
YEARS OF AGE
C
ompl
ete t
his section only if
“Grandparent” Caregiver Category checked.
Lis
t
the
total number of qualify
ing children and total number of qualifying disabled adults being care for in the
home. Check all applicable “Relationships” to the child(ren) and disabled adult(s).
SECTIO
N V
:
CAREGIVER FOR ADUL
T
C
heck
the a
pplicable “Relationship”
. A separate section for each adult care recipient is required.
SECTION VI: ADULT CARE RECIPIENT #1 INFORMATION:
C
ompl
ete al
l “Adult Care Recipient
#1” information.
SE
CT
ION
VII: CAREGIVER
SERVICE PLAN
Enter C
are
Rec
ipient No. (e.g. Recipie
nt #1, 2, or 3) for applicable adult or leave column blank if “Grandparent
caring for grandchild(ren) < 19 years of age” Caregiver;
Ente
r
Serv
ice Code; Provider Name; Unit
s; Per (day or week); Total Units (per month); Service Start Date; and
Service End Date.
Ente
r a Di
scha
rge Code when the Caregiver no long
er receives a service.
SECTION VIII: ADULT CARE RECIPIENT #2
C
ompl
ete al
l “Adult Care Recipient
” information for a second adult if two or more adults are care recipients.
SE
CT
ION
IX: ADULT CARE RECIP
IENT #3
C
ompl
ete al
l “Adult Care Recipient
” information for a third adult if three or more adults are care recipients.
(Addi
ti
onal
forms may be used if more than th
ree adults are care recipients.)
SECTION X: NOTES
T
hi
s sec
tion is available for the I
nterviewer to record any information that may be applicable.
Contact the KDADS Family Caregiver Support Program Manager at 1-800-432-3535 if you have questions
regarding this form.
22
Kansas III-E Caregiver Assessment Plan
KDO
A
Form SS-025 (10/01/10)
KAMIS DATA ENTRY REQUIREMENTS
The III-E Caregiver Assessment Plan (CAP) (SS-025) must be entered into KAMIS before the 20
th
day of the month
f
oll
owi
ng the month in which servi
ces were provided. The Caregiver Service Plan’s Start Date entered into KAMIS
allows Caregiver Service providers to be reimbursed effective with this date of service. In addition, the AAA must
verify the Group I Services provided and submit through the KAMIS 225 process before the 20
th
day of the
mont
h following the month i
n which ser
vices were provided.
Following is a list
of required KAMIS fields:
SE
CT
ION
I INTAKE:
Interviewer, PSA,
Date of Assessment, Initial or Reassessment designation
SECTION II CAREGIVER CATEGORY:
Caregiver or Grandparent
If Grandparent, select caring for grandchild(ren) < 19 years of age or caring for disabled adult(s) 19 - 59 years of age, or
both if applicable
SECTION III CAREGIVER INFORMATION:
The following caregiver information must be entered:
Name, date of birth, gender, ethnicity, race, city, county, state, urban/rural designation
SECTION IV GRANDPARENT CAREGIVER CATEGORY (Required if “Grandparent” funding checked in
Section II):
Number of children and number of disabled adults, if applicable
Relationship to child/children and disabled adult(s), if applicable
SECTION V CAREGIVER for ADULT
Relationship to Recipient
SECTION VI ADULT CARE RECIPIENT #1 (Required if “Caregiver” funding checked in Section II):
Qualifying Care Recipient
SECTION VII CAREGIVER SERVICE PLAN
The fo
ll
owi
ng information must be enter
ed to initiate services:
Recipient No., Service Code, Provider Name, Units, Per, Total Units, Start Date, End Date
(Note: The End Date shall be the date the service is to terminate or one year from the Start Date, whichever comes first.)
Discharge Code shall be entered when the service is terminated.
SECTION VIII ADULT CARE RECIPIENT #2 (Complete if more than one adult is a care recipient):
Relationship to Recipient
Qualifying Care Recipient
SECTION IX ADULT CARE RECIPIENT #3 (Complete if more than two adults are care recipients):
Relat
ion
ship t
o Recipient
Qualifying Car
e Recipient
SECTION X NOTES:
None
23
Kansas III-E Caregiver Assessment Plan
P
A
F
4016
02/2015
INSTRUCTIO
NS FOR COM
PLETING NATIONAL FAM
ILY CAREG
IVER SUPPORT
PROGRAM INTAKE FORM
The initial intake can be taken in person or over the telephone. Explain to Caregiver (Client) that
all information provided will be kept confidential. Conduct intake in a secure setting where
privacy can be protected.
1. S
ection A: Agency/Organization Information
Enter D
ate of Request/Referral, Method of Contac
t, Assessor Name, Agency Name
2. S
ection B: Initial Screening and Intake
Choose
appropriate category for Client st
atus. If client is a Family Caregiver, enter the
relationship to the Qualifying Individual.
3. Obta
in and record qualifying individual’s identifying information.
4. S
e
ction C: Caregiver Information
Obtain and re
cord Client identifying information. Explain that this will be
used to
establish an Identification Number that can be used to keep report the services the Client
receives to the funding source. Enter the last four digits of the Caregiver’s Social
Security Number only. Create the Louisiana Identification Number using his/her date of
birth and the last four digits of SSN (e.g., Client born June 20, 1926 = ID#
062019268333)
5.
S
ec
tion D: Determine Client eligibility for p
riority status. Chec
k Appr
opriate box
.
Greatest Economic Need, Greatest Social Ne
ed, and individual providing care for person
who ha
s dev
e
lopme
ntal disability are determined based upon se
lf-reported data.
a. Gr
e
a
test Economi
c Need- Ask for the number of persons in the C
lient’s
house
hold. The
n c
hec
k the chart below and ask whether the annual income more
or less than the amount in the corresponding column.
2015 HH
S P
overty Guidelines
1
S
iz
e
of Fa
mily Unit
48 Co
nti
g
uous State
s &
D.C.
1
$ 11,770
2
$15,930
3
$20,090
4
$24,250
5
$28,410
6
$32,570
7
$36,730
8
$40,890
1
SO
URCE:
Federal Register
, Vol. 79, No. 14, January, 22, 2014, pp. 3593-3594
24
Louisiana Instructions and Intake Assessment Form
PAF 4016
02/2015
F
or each additional
pe
rson, add
$4,160
b.
Greatest Social Need - Determine whe
ther the Client has any of the following problems:
phy
sical and mental disabilities;
language barr
iers (difficulty understanding or speaking English); or
cultural, social, or geographical isolation, including isolation caused by racial or
ethnic status, that - restricts the ability of an individual to perform normal
daily tasks; or threatens the capacity of the individual to live
indepe
ndently.
c. Either a letter of Eligibility from the Office of Citizens with Developmental Disabilities
(OCDD) or a doctor’s statement can be used to verify eligibility for priority status under
the National Family Caregiver Support Program due to a developmental disability. If the
qualifying individual has not received a letter of Eligibility from OCDD, provide Client a
copy of DOCTOR’S STATEMENT FORM to be signed and returned before services
are authorized. The DOCTOR’S STATEMENT FORM or a
copy of the Letter of
Eligibility will become a permanent part of Client records.
6. Eligibility for Respite Care, Material Aid, Personal Care and Sitter Service
a. Ask the Client to describe the type of assistance the quali
fying individual requires.
b. Ask whether the qualifying individual can be left alone, and if not, why not?
c. Check appropriate box(es).
7. Describe the type of assistance or information requested by the Client.
8. Obtain directions from the area age
ncy on aging to the home of the qualifying individual.
9. If Client needs Respite Care, Material Aid, P
ersonal Care or Sitter Service proceed to step 10. If
not, skip to step 12.
10. Complete the Family
Caregiver Support Program Score Sheet. Leave item #11 blank until the
caregiver stress level is obtained from the Caregiver Stress Interview.
11. Complete the Caregiver Stress Interview. Record the caregiver stress level on the Score Sheet and
calculate the Total Score. Record the Total Score on Page 1 of the Intake Form.
12. Explain and provide Client with a copy of the area agency’s policy regarding participant
contributions and grievance procedure.
13. Have
Client sign and date Intake Form.
14. Complete Initial Contact information at the top of the Intake
Form. Sign and date form.
15. Clients must be reassessed annually.
25
Louisiana Instructions and Intake Assessment Form
Nam
e
of
Client (Car
egiver): ID#:
PAF 4016
02/2015
N
AT
IONAL FAMILY
CAREGIVER SUPPORT PROGRAM
INTAKE ASSESSMENT FORM
S
E
CTIO
N A:
AG
E
NC
Y/ORGAN
IZATION INFORMATION
Da
t
e
of
Request or Referral
: ______________
M
et
ho
d of
Contact
:
telep
h
o
ne
f
ac
e-to-f
ac
e
M
o
nt
h/D
ay/Year
o
th
er
Ass
ess
o
r Na
me
:
_
_
__
______________
_______
Ag
e
n
cy
Name:
________________________________
S
E
CTIO
N B: INITIAL S
CREENING AND INTAKE
P
E
RSO
N PROVID
ING ANSWERS AND INFORMATION FOR ASSESS
MENT:
C
ar
eg
iver
Frie
n
d
/neig
hbor
L
eg
al
gu
ardian or surrogate
decision
-m
ak
er
Fam
ily
mem
ber
Oth
er
pr
ofessional (e.g. care
manager)
P
RIM
AR
Y LANG
UAGE:
E
n
g
lish
Sp
an
is
h
Fre
n
ch
Oth
er
__
______________
_________________
QUALIF
YIN
G
INDIVIDU
AL (Person receiving care):
Nam
e:
________________________________
Addre
ss:___________________________________
State: _
_
_
__
_______ Zip C
ode: __________ Parish: ______________ Phone: ________________
So
cial
Secu
rity
Number: _________
______________ Date of Birth: ________
_________
C
ar
eg
iver
by Relationship
Hu
s
b
and
W
if
e
So
n
/So
n
-in-law
Dau
g
h
ter/Dau
ghter
-in-law
Oth
er
Relativ
e
No
n
-R
elativ
e
S
E
CTIO
N C: C
AREGIVER INFORMATION
S
oc
ial
Se
curity Number
:--
L
ou
isi
ana Id
entification Number
: 
L
a
s
t
Name
: _
_
_
__
______________
__
F
irst
Na
me
: _
_
_
__
______________
________
MI: _
_
_
__
___
Address:_
_
_
__
______________
________
Apt
.
#
: _
_
_
__
_______
P
a
rish: _
_
_
__
______________
___
Sta
t
e: _
_
_
__
___
Z
ip Co
de: _
_
_
__
____
T
elepho
ne
(H
ome)
: _
_
_
__
_______
Wo
rk
: _
_
_____________
DO
B
: _
_
_
__
______________
________
Rura
l/I
s
ola
ted
: Yes No
Mo
n
th
/Day/Yea
r
G
ender
: Ma
le
Fem
ale
Ra
ce
: W
h
it
e
(Alone)
Blac
k
or
African American (Alon
e)
A
m
e
rican
Indian/Alaskan Native
(Alone)
Na
ti
v
e
Hawaiian/Other Pacific Islan
der
A
sia
n
(A
lone)
De
c
li
ne
d to Respond
Oth
e
r_
__
______________
____
M
a
rit
al St
atus
: Ne
v
e
r M
arried
M
a
rried
P
a
rtn
er/S
ignificant Other
W
id
o
we
d
S
e
p
ara
ted
Div
o
rc
ed
26
Louisiana Instructions and Intake Assessment Form
Nam
e
of
Client (Car
egiver): ID#:
PAF 4016
02/2015
Eth
n
icity: Hisp
a
n
ic/La
tino
No
t
His
p
an
ic/Latin
o
N
A
T
IO
NAL FAMILY CAR
EGIVER SUPPORT PROGRAM
INTAKE ASSESSMENT FORM (CONTINUED)
Name of Client (Caregiver): ___________________________ ID #: _____________
S
E
CTIO
N D: P
riority
S
tat
u
s (ch
eck all that apply)
C
li
e
nt is an o
lder individual in greatest economic need
C
li
e
nt is an o
lder individual in greatest social need
C
li
e
nt is an o
lder individual providing care and support to person who has a developm
ental disability
E
li
gib
ility f
or Respite Care, Personal Care, Mat
erial Aid and Sitter Service
(c
h
e
ck
all that apply
– at
least
on
e m
ust apply to be eligible):
The
qua
li
fying
individual is unable to perform at least two of the following ac
tivities without
subst
a
nti
al hu
man a
ssi
stanc
e, including
verbal reminding, physical cueing, or supervision: bathing
;
dr
e
ssi
ng; t
oileting; transferring; walking: eati
ng.
The
qua
li
fying
individual has a cognitive or other mental impairment, requires subs
tantial supervision
be
c
a
use the
indi
vidual be
ha
ves in a ma
nner that poses a serious health or safety haza
rd to the individual
or
to anothe
r indivi
dual.
De
sc
r
ibe
the type of assistance neede
d {continue on supplemental sheet(s)}:
Dir
e
c
tions t
o Home of Qualifying Individual
{
c
on
tinue
on supplemental sheet(s)}:
-----------------------------------------------------------------------------------------------------------------------------
--
I h
ave r
eceived a copy of the grievance proced
ure and contribution policy.
_________________________________ _____________________________
27
Louisiana Instructions and Intake Assessment Form
Nam
e
of
Client (Car
egiver): ID#:
PAF 4016
02/2015
Dat
e
Signature of
Caregiver
_________________________________ ______________________________
Date Signature of Intake Worker
Family Caregiver Support Program Score Sheet
1. The
c
a
reg
iver's income level is at or below the federal poverty li
ne.
No =
0 Ye
s =
1
2. The
c
a
reg
iver has "greatest social need." No = 0 Yes = 1
3. The
c
a
reg
iver is 60 years of age or older and providing
care and support to
pe
rson tha
t has a
deve
lopmental disability. No = 0 Yes = 1
4. Ag
e
of c
are
giver:
Unde
r 60 =
0 60 -74 y
e
a
rs of a
ge = 1 75 years of age or older = 2
5. How
doe
s the c
are
giver rate her/his overall health?
Good =
0 F
a
ir = 1 P
oor = 2
6. F
or
how ma
ny qua
lifying individuals is this caregiver the primary
c
a
re
giver
? (One point for each qualifying indi
vidual)
7. How
many
hour
s of dire
ct care on average each day doe
s the caregiver
pr
ovide to the qua
li
fying
individual?
8 hour
s or le
ss = 0 9 - 16 hour
s=
1 17 - 24 hour
s =
2
8. I
s the c
a
reg
iver employed?
No =
0 P
a
rt
-ti
me =
1 F
ull
- ti
me (
35 or
more hour
s/week) = 2
9. W
it
h how ma
ny of the
following activities of daily living doe
s the caregiver
pr
ovide a
ssi
s
tanc
e
to t
he qua
lifying individual? (one point for each
-
c
irc
le a
ll that a
pply)
B
AT
HI
NG
DRESSING
T
OI
L
ET
ING TRANSF
E
R
R
ING
WALKING
E
AT
I
NG
10. Doe
s the qua
li
fying
individual receive assistance with any of the
a
c
ti
vities in que
stion 9 from any other source? Yes = 0 No = 1
11. C
a
re
giver
Stress Level:
2
L
it
tl
e/No S
tress
=
0
Mi
ld/
Moder
ate =
1
Moder
a
te/S
eve
re Stress
=
2
S
e
ve
re S
tress = 3
T
OT
AL S
COR
E
2
F
r
om
Care
giver Stress Interview
28
Louisiana Instructions and Intake Assessment Form
Nam
e
of
Client (Car
egiver): ID#:
PAF 4016
02/2015
29
Louisiana Instructions and Intake Assessment Form
Nam
e
of
Client (Car
egiver): ID#:
PAF 4016
02/2015
CA
REGIV
ER STRESS INTERVIEW
Re
ad to C
aregiv
er: The following is a list of statements which reflect how people sometimes feel when taking
c
a
re
of another
person. After each statement, indicate how ofte
n you feel that way: never, rarely, sometimes,
quit
e frequently, or nearly always.
There are no right or wrong answers.
QUE
S
T
ION
N
e
ve
r
(0)
R
ar
e
ly
(1)
S
om
e
tim
es
(2)
Q
u
i
te
F
r
e
qu
ently
(3)
N
e
ar
ly
A
l
w
ays
(4)
S
c
or
e
1. Do y
ou fe
e
l tha
t your relative asks for
more
he
lp t
han he
/she needs?
2. Do y
ou fe
e
l tha
t bec
a
use o
f the
ti
me y
ou
spend
with y
our r
elative tha
t you don’t
ha
ve
e
nough
ti
me f
or
yourse
lf?
3. Do y
ou fe
e
l stre
ssed between caring for
y
our r
e
lative and try
ing to meet other
re
sponsi
bil
ities f
or your family or work?
4. Do y
ou fe
e
l embarr
assed over your
re
lative’
s beh
avior?
5. Do y
ou fe
e
l angry
when you are around
y
our r
e
lative?
6. Do y
ou fe
e
l tha
t your relative currently
a
ff
e
cts y
our relationship with other family
membe
rs
or
f
rie
nds in a
negative way?
7. Ar
e
y
ou afr
aid of what the future holds for
y
our r
e
lative?
8. Do y
ou fe
e
l your r
elative is dependent
upon y
ou?
9. Do y
ou fe
e
l stra
ined
whe
n y
ou a
re a
round
y
our r
e
lative?
10. Do y
ou fe
e
l your h
ealth has suffered
be
c
a
use of y
our involvement with your
re
lative?
11. Do y
ou fe
e
l tha
t you don’t have as much
pr
ivac
y
as y
ou would like
be
c
a
use of y
our
30
Louisiana Instructions and Intake Assessment Form
Nam
e
of
Client (Car
egiver): ID#:
PAF 4016
02/2015
QUE
S
T
ION
N
e
ve
r
(0)
R
ar
e
ly
(1)
S
om
e
tim
es
(2)
Q
u
i
te
F
r
e
qu
ently
(3)
N
e
ar
ly
A
l
w
ays
(4)
S
c
or
e
re
lative?
12. Do y
ou fe
e
l tha
t your social life has
suff
e
re
d bec
ause you are caring for your
re
lative?
13. Do y
ou fe
e
l uncomfor
table about
ha
ving
fr
iends visi
t y
ou bec
ause you are caring for
y
our r
e
lative?
14. Do y
ou fe
e
l tha
t your relative seems to
e
x
pe
ct y
ou to take care of him/her as if you
we
re
the only
one he
/she could depend on?
15. Do y
ou fe
e
l tha
t you don’t have enough
money
to ca
re
for
your relative in
a
ddit
ion
to t
he
r
est of y
our expenses?
16. Do y
ou fe
e
l tha
t you will be unable to take
c
a
re
of your r
elative much longer?
17. Do y
ou fe
e
l you ha
ve lost control of your
li
fe
since
your r
elative’s illness?
18. Do y
ou wish y
ou c
ould just l
eave the care
of y
our r
e
lative to some
one
e
lse?
19. Do y
ou fe
e
l
unc
e
rta
in about what t
o do
a
bout y
our r
elative?
20. Do y
ou fe
e
l you shoul
d be doing more for
y
our r
e
lative?
21. Do y
ou fe
e
l you c
ould do a better job in
c
a
ring
for
your relative?
22. Ove
ra
ll
, do you fe
el burdened caring for
y
our r
e
lative?
CA
REG
IVER S
TRES
S LEVEL:
2
2
The
c
a
regiver stress level is calculated by summing
the scores of the individual items as follows:
0 -
20
=
Little/No Stress 21 - 40 = Mild/Moderate Stress
41-
60 = Moderate/Severe Stress; 61 - 88 = S
evere Stress
31
Louisiana Instructions and Intake Assessment Form
Nam
e
of
Client (Car
egiver): ID#:
PAF 4016
02/2015
CLIE
NT SE
RVICE RECORD
(copy as neede
d)
App
r
ove
d S
ervices
S
e
r
vice P
rovider
B
e
gin
nin
g
S
e
r
vice Dat
e
E
n
d
ing S
ervice
Dat
e
32
Louisiana Instructions and Intake Assessment Form
Nam
e
of
Client (Car
egiver): ID#:
PAF 4016
02/2015
App
r
ove
d S
ervices
S
e
r
vice P
rovider
B
e
gin
nin
g
S
e
r
vice Dat
e
E
n
d
ing S
ervice
Dat
e
S
UP
PLE
ME
NTAL SHEET
(copy as needed)
33
Louisiana Instructions and Intake Assessment Form
Nam
e
of
Client (Car
egiver): ID#:
34
Louisiana Instructions and Intake Assessment Form
Nam
e
of
Client (Car
egiver): ID#:
NATIONAL FAMILY CAR
EGIVER SUPPORT PROGRAM
DOCTOR’S STATEMENT FORM
This is to verify that I have personally examined
(Name of Qualifying Individual)
and found him/her to have the following:
A diagnosis of developmental disability.Developmental disabilityrefers to significantly sub-
a
verage general intellectual function e
xisting concurrently with deficits in adaptive behavior and
manifested prior to age 22; or
A severe, chronic disability which is attributable to developmental disability, cerebral palsy,
epilepsy or autism; or any other condition, other than mental illness, found to be closely related to
developmental disabilitybecause this condition results in impairment of general intellectual functioning or
adaptive behavior similar to that of persons with developmental disabilityor requires treatment of services
similar to those required for these persons; the disability:
i. is manifested before the person reaches age 22;
ii. is likely to continue indefinitely;
iii. results in substantial functional limitations in three or more of the following
areas of major life activity: self-care; understanding and use of language; learning; mobility; self-
direction; capacity for independent living; economic self-sufficiency; and
iv. reflects the individual's need for a combination and sequence of special,
interdisciplinary, or generic services, supports, or other assistance that is of lifelong or extended duration
and is individually planned and coordinated; or
Substantial developmental delay or specific congenital or acquired conditions with a high
probability of resulting in developmental disabilities if services described in iv, above, are not provided
(applies to individuals from birth to age 5).
S
ig
na
ture
Da
te
35
Louisiana Instructions and Intake Assessment Form
FC
SP v1
.0
.1
S
ECT
IO
N I: REFERRAL SO
URCE
REFE
RR
AL
SOURCE
How did you c
omplete this assessment?
In Person
Over the Phone
Who referred the caregiver to have a caregiver
assessment?
Adult Day Health Care Center
AFC
Caregiver (self-referral)
Caregiver Specialist
Case Manager
COA
Family
Friend
GAFC
Health Professional (e.g. Doctor, Hospital, Discharge
Planner)
Information & Referral
Intake Specialist
Mental Health Professional
Options Counselor
Other
SCO
SHINE
VA
Visiting Nurses Association (VNA)
If Other, please specify.
FCSP v1.0.1
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Massachusetts Caregiver Assessment Tool 2015
S
ECT
IO
N II: CAREGIVER CO
NTACT INFORMATION AND
CARE
GIV
IN
G SITUATION
CONTACT I
NFORMATION
What is the caregiver's last name?
What is the caregiver's first name?
Address
City/Town
Enter the caregiver's state of residence.
Zip Code
Home Telephone Number
Cell Phone Number
Work Phone Number
E-mail Address
Does the caregiver live with the care recipient?
Same structure/separate living area
No
Yes
How far away does the caregiver live from the care
recipient?
Within a 1/2 hour
1/2 hour to hour
Over an hour
Out of State
Out of Country
Not applicable
What is the caregiver relationship to care recipient?
Please select one.
Husband
Wife
Domestic Partner / Significant Other
Same Sex Partner
Son/Son-in-Law
Daughter/Daughter-in-Law
Other Relative
Non-Relative
Grandparent
Other Elderly Relative
Other Elderly Non-Relative
What is the caregiver's date of birth?
______/______/____________
Caregiver's gender
Declined to Disclose
Female
FTM - Female to Male
Male
MTF - Male to Female
Other
Transgendered
Unknown
How long has caregiver provided assistance? Please pick
one of the answers below using the nearest whole year.
Less than 1 year
1 to 2 years
3 to 5 years
6 to 10 years
11 years or longer
How many hours per week does the caregiver spend on
caregiving?
1-5 hours
6-10 hours
11-20 hours
21-35 hours
36+ hours
24 X 7
Is the caregiver also a caregiver for another person?
No
Yes
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Massachusetts Caregiver Assessment Tool 2015
Who
el
se
is the caregiver responsib
le for? (Check all that
apply
)
Ch
il
d(ren)
Domestic Partner/S
ignificant Other
Same Sex Partner
Grandchild(ren)
Other Family Members
Spouse
Not Applicable
Do the responsibilities include anyone with special
needs/medical conditions/disabled?
No
Yes
Not Applicable
Is the caregiver employed? Please pick one of the
answers below.
Yes, employed full-time
Yes, employed part-time
Not working, would like employment
Seeking employment
No, not employed
What is the caregiver's primary language?
English
French
Spanish
Albanian
American Sign Language (ASL)
Amharic
Arabic
Armenian
Bengali
Bosnian
Bulgarian
Cambodian (Khmer)
Cape Verdean Creole
Chinese - Cantonese
Chinese - Mandarin
Chinese - Toisanese
Chinese - Other
Croatian
Dutch
Ethiopian
Farsi / Iranian / Persian
French Creole
German
Greek
Gujarati
Haitian Creole
Hebrew
Hindi
Hmong
Hungarian
Italian
Japanese
Korean
Kutchi
Laotian
Lithuanian
Nepali
Polish
Portuguese
Punjabi
Romanian
Russian
Serbian-Cyrillic
Slovenian
Somali
Swahili
Swedish
Tagalog
Tamil
Thai
Turkish
Urdu
Vietnamese
Other (specify 'Other' language in Notes field)
FCSP v1.0.1
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Massachusetts Caregiver Assessment Tool 2015
S
ECT
IO
N III: CARE RECIPI
ENT'S CHARACTERISTICS
CARE
R
ECI
PIENT'S CHARACTERIS
TICS
What is the care recipient's first name?
What is the care recipient's last name?
Is the Care Recipient a client of the AAA/ASAP?
No
On Waitlist
Unknown
Yes
Which program(s) is the care recipient enrolled in?
AFC
Community Choices
ECOP
GAFC
Home Care Basic (non-waiver)
Home Care Basic (waiver)
Napis/Meals
PCA
Private Pay Care Management
Respite Over-Income
SCO
Not Enrolled in Any Program
Unknown to Caregiver
Other
H
ow di
d the caregiver explain the c
are recipient's present
phys
ical
/mental health? Check all
that apply.
A
lzhei
mer's disease
Arth
ritis
C
ance
r
Dementia ot
her than Alzheimer's disease
Diabetes
Fractured bone/osteoporosis
Frail
Hearing impairment
Heart/circulation
Infection
Mental health concern
Neurological Disorder
Oral Health
Respiratory
Visual impairment
Other
If Other is checked, how does the caregiver explain the
care recipient's present physical/mental health.
Does the care recipient have a health care proxy?
No
Yes
Unknown
A. SUPPORT OTHER THAN ADLS AND IADLS
Who advocates or facilitates participation in health care
for the care recipient?
Private pay
Caregiver
Independent
Non-paid family, friends and/or volunteers
Program Paid
Unmet
Environmental support (housing, home maintenance) for
the care recipient?
Private pay
Caregiver
Independent
Non-paid family, friends and/or volunteers
Program Paid
Unmet
Who helps the care recipient with legal matters?
Private pay
Caregiver
Independent
Non-paid family, friends and/or volunteers
Program Paid
Unmet
Who is the care recipient's power of attorney /
conservator?
Private pay
Caregiver
Independent
Non-paid family, friends and/or volunteers
Program Paid
Unmet
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Massachusetts Caregiver Assessment Tool 2015
Who
hel
ps
with the care recipient's ps
ychosocial support?
Priv
at
e
pay
Caregiver
Independent
No
n-paid family, friends and/or volunteers
Program Paid
Unmet
B: HELP WITH ACTIVITIES OF DAILY LIVING
Who helps with bathing?
Private pay
Caregiver
Independent
Non-paid family, friends and/or volunteers
Program Paid
Unmet
Who helps with dressing?
Private pay
Caregiver
Independent
Non-paid family, friends and/or volunteers
Program Paid
Unmet
Who helps with eating?
Private pay
Caregiver
Independent
Non-paid family, friends and/or volunteers
Program Paid
Unmet
Who helps with personal hygiene?
Private pay
Caregiver
Independent
Non-paid family, friends and/or volunteers
Program Paid
Unmet
Who helps with toileting?
Private pay
Caregiver
Independent
Non-paid family, friends and/or volunteers
Program Paid
Unmet
C: HELP WITH INSTRUMENTAL ACTIVITIES OF DAILY
LIVING
Who helps with Heavy Housework?
Private pay
Caregiver
Independent
Non-paid family, friends and/or volunteers
Program Paid
Unmet
Who provides assistance with laundry?
Private pay
Caregiver
Independent
Non-paid family, friends and/or volunteers
Program Paid
Unmet
Who helps with managing finances?
Private pay
Caregiver
Independent
Non-paid family, friends and/or volunteers
Program Paid
Unmet
Who helps with medication management?
Private pay
Caregiver
Independent
Non-paid family, friends and/or volunteers
Program Paid
Unmet
Who helps with mobility?
Private pay
Caregiver
Independent
Non-paid family, friends and/or volunteers
Program Paid
Unmet
Who helps with using the phone?
Private pay
Caregiver
Independent
Non-paid family, friends and/or volunteers
Program Paid
Unmet
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Massachusetts Caregiver Assessment Tool 2015
Who
hel
ps
with meal preparation?
Priv
at
e
pa
y
Caregiver
Independent
No
n-paid family, friends and/or volunteers
Program Paid
Unmet
Who helps with shopping?
Private pay
Caregiver
Independent
Non-paid family, friends and/or volunteers
Program Paid
Unmet
Who provides transportation to activities?
Private pay
Caregiver
Independent
Non-paid family, friends and/or volunteers
Program Paid
Unmet
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Massachusetts Caregiver Assessment Tool 2015
S
ECT
IO
N IV: CAREGIVER S
ERVICE ASSESSMENT
A.
CARE
GIV
ER'S NEEDS
What are the c
aregiver's immediate needs/concerns that
prompted this assessment? Check all that apply.
Accessing services for the care recipient.
Addressing personal concerns other than caregiver
responsibilities.
Balancing work and caregiving responsibilities.
Dealing with own physical health.
Financial strain/constraints.
Home modification.
Immediate care of care recipient.
Managing other family responsibilities.
Managing the care recipient's medications.
Other
Respite
Safety issue/care recipient at risk of falling or left
unsupervised.
Understanding and managing the care recipient's health
needs.
Understanding and managing the behavior of the care
recipient.
Does the caregiver wish to continue her/his caregiving
role? If No or Unknown, please make comments in the
Notes section.
No
Unknown
Unsure
Yes
Do
es the c
aregiver feel s/he has the nec
essary ability and
know
ledge to
care for the care recipient?
If No or
Unknown, please make comments in the Notes section.
No
Unknown
Unsure
Yes
What caregiver support system(s) does the caregiver rely
on? Check all that apply.
Community Resources
Faith Community
Counseling
Family
Support Groups
Neighbors/Friends
Do
es the c
aregiver have a back-
up pl
an for
her/himself in
the event s/he unexpec
tedly could not assist the care
recipient?
No
Y
es
I
f the caregiver has a back-up plan, is it adequate?
No
Yes
Not Applicable
I
f caregi
ver doesn't have back-
up pl
an, w
ould they like to
develop
one?
No
Y
es
No
t Applicable
B. CAREGIVER'S PERSONAL HEALTH AND WELL-BEING
How does the caregiver rate his/her health?
Excellent
Good
Fair
Poor
Unknown
Is this a change from 3 months ago?
No
Unknown
Yes, Deteriorated
Yes, Improved
Not Applicable
How does the caregiver rate her/his emotional health at
the present time?
Excellent
Good
Fair
Poor
Unknown
Is this a change from 3 months ago?
No
Unknown
Yes, deteriorated
Yes, improved
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Massachusetts Caregiver Assessment Tool 2015
When
prov
idi
ng care to the care recipient,
what
situa
tio
ns
are stressful for the caregiv
er? Check all that
apply from the list below and use "other" for additional
situations. When the care recipient...
Gets up at night (often)
Has bowel or bladder "accident"
Has unexpected health or behavior changes
Is left alone -- possible safety issues
Is threatening to others (verbal or physical)
Is uncooperative (e.g. refuses to take medications)
Is unwilling to accept assistance/services from others
Repeats questions/stories
Requires care causing the CG time away from spouse,
children and/or family.
Requires care causing the CG to miss work, leave early,
reduce hours
Requires care that causes changes in personal plan&
decline in social activities
Is at risk of falling/falls often
Financial problems
Not understanding how to care for client
Is restless or agitated
Wanders
Other
Does the caregiver have a self-care plan that includes
stress reduction for herself/himself?
No
Unknown
Yes
Does the plan include any of the following options?
(Check all that are known.)
Ensuring leisure time
Exercise/Sports
Hobbies
Keeping appointments (i.e. medical / counseling)
Meditation
Social Activities
Spirituality
Support Group
Other
Does the caregiver believe s/he is spending enough time
and attention to her/his own well-being?
Most of the time
Seldom
Never
Unknown
Does the caregiver feel a sense of satisfaction or other
positive feelings helping the care recipient?
Yes
No
Unknown
What services and support options were discussed with
the caregiver to meet his/her needs? Check all that
apply.
Activities for care recipient
Adult Day Health Programs
Children's camperships / after school programs
Dealing with stress; stress reduction/relaxation exercises
E
duca
ti
on/ski
ll
bu
ilding (e.g.
mana
ging behavior, personal
care)
E
nd of
Life Issues
Frie
ndly
Visi
tor
Health Care
Proxy
Help involving family members in caregiving
tasks/facilitated family meeting.
Home modification/safety concerns
Homemaker
Hospice
Housekeeping
Housing
Insurance and benefits counseling
Legal information/referral
Meals
Medicaid (General Info)
Mental health referral for care recipient
On-going reassurances
On-going respite
Other
Personal care
Personal concerns -- caregiver referral to counseling
Planned respite (one-time)
Powerful Tools for Caregivers
Referral to Options Counselor
Referral to SHINE
Referral to support group
Shopping
Subsidy/Scholarship - Respite
Subsidy/Scholarship - Supplemental Assistance
Telephone reassurance
Transportation
Veterans Benefits Assistance
If Other, what services and support options were
discussed with the caregiver to meet her/his current
concerns / needs, please specify.
FCSP v1.0.1
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Massachusetts Caregiver Assessment Tool 2015
Wa
s
a
caregiver action plan dev
eloped after the
ass
ess
ment w
as completed?
Yes
No
Signature:
Date
______/______/____________
Da
te
Title :
Date
Title :
FCSP v1.0.1
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Massachusetts Caregiver Assessment Tool 2015
M
BA
0
1.28.14 Rev’d
MBA Title III-E C
aregiver
Questionnaire
Contents Initials/Date
Part I: Demographics (NAPIS data)
Part II: Caregiving Questions
Part III: Caregiver Screens
Part IV: Closing Questions
Part V. Caregiver Plan
Additional Tool: Live Well at Home Rapid Screen
SM
45
Minnesota Title III-E Caregiver Questionnaire
Part
I
. C
ar
eg
i
v
er Program Registrat
ion
P
lea
se compl
ete this form to t
he best of your ability. Shaded areas are for office use
on
ly
.
C
ontact
Da
te
/ /
Stat
us
A
AA
Regi
on
N
AP
IS ID Nu
mber
- -
S
ec
tion A
. Basic Demographics
Last
Nam
e:
Fir
st
Nam
e:
Mi
ddl
e Ini
tial:
Liv
es i
n Ru
ral Area (Circle O
ne):
Y
es  N
o
G
ender
: 
F
emal
e  Ma
le
U
nspeci
fi
ed
D
ate o
f B
irth:
/
/
A
ddres
s:
A
ddres
s #2:
C
it
y:
Sta
te:
Z
ip C
ode:
C
ounty
:
H
ome Phone:
(
)
Mobi
le Ph
one:
(
)
Wor
k Phone
:
(
)
S
ec
tion B.
S
ocia
l His
tory
R
ace (
Ci
rcle one):  American I
ndian/Alaskan  Asian
Whi
te H
isp
ani
c
Whi
t
e not
H
i
spa
ni
c
2 or
More Races
 B
lac
k/
African American  Nati
ve Hawaiian/Pacific Islander 
O
ther
Ethni
cit
y (
Ci
r
cle
one)
 H
isp
anic or
L
at
i
no
 N
on
-H
ispa
nic
S
ec
tion C.
Care Receiver
Wha
t i
s t
he care receiver’s name?
(
Last
)__
______________________________ (First)__________
_____________________ (Middle Initial)______
Wha
t i
s t
he care receiver’s date
of
b
ir
th?
______/_________/________
Wha
t i
s your
relationship to the car
e receiver? (Circle one)
 H
usband
 Wi
fe  Son/Son
-in-l
aw  D
aug
hter/Daughter
-in-l
aw  Ot
her
Relative
 N
on
-R
elat
iv
e

Wha
t i
s t
he approximate household income of
the care receiver?
(
Ci
rcl
e one)
1 per
son in a s
ing
le or multiple,
non-spous
al
ho
useh
old
U
nder $9
73/
mont
h
$973 t
o $1,4
59/
mont
h $1,4
60 t
o $1,9
45/
mont
h Mo
re than $1,9
45/
mont
h
2 per
son
sp
ousal
hou
seho
ld
U
nder $1,
3
11/
mont
h $1,
31
1
t
o $1,9
66/
mont
h $1,9
67 t
o $2,
6
22
/
mont
h Mo
re than $2,
622/
mont
h
S
ec
tion D.
Use of Information
I
und
ersta
nd that the information I am providin
g on this form is for registration purposes.
The
infor
mation
will
be
used
by the Area Agency
on Aging and the Minnesota Board on Aging to create statistical reports
a
nd ma
y
be used by service providers
to help identify other services from which I may benefit. This
infor
mation will
not
be released t
o
an
yon
e other than the above mentioned pa
rties in a way that will
identif
y me
as an indivi
dual unless I sign a separate consent for that pu
rpose.
S
igna
ture: ___________
___________________________
_____ Toda
y’s
Date: _______________
_____
46
Minnesota Title III-E Caregiver Questionnaire
Part
II.
Car
egiving Questions
W
hat
i
s your most immediate ne
ed or concern?
H
ow
di
d you hear about this
agency/organization?
Br
ochur
e
N
ew
spa
per
Fri
end
or
acquaintance
I
nter
net
W
ebsi
te
Doc
tor/h
eal
th clinic
Comm
uni
ty
service/program
O
ther
A
re
yo
u
c
urr
entl
y employed? (Please describe)
W
or
ki
ng full
-tim
e
W
ork
in
g part
-tim
e
N
ot Cu
rr
ently Employed
Do
yo
u
li
ve in the same househol
d as
t
he
per
son
needing care
?
Ye
s
N
o
If not, what is the d
istance between households? _____ miles
I
s t
her
e anyone else living w
ith you or <NOP> that needs your care or time (e.g.,
min
or
c
hildren,
pa
re
nt, or
other dependent)
?
H
ow
wou
ld you describe your
own health?
E
xcel
le
nt
G
ood
Fa
ir
Poor
W
hat
i
llnesses or medica
l problems do YOU have that limit
yo
ur
ab
ility to provide car
e,
a
nd
do
what you need to do? (e.g.,
chronic pain, diabetes, emphysema, Parkinson’s
,
phys
ic
al
disabilities, mental
illness)
Do
you
hav
e difficulty getting a
good night’s sleep, 3 or more times per week?
Ye
s
No
Somet
ime
s
N
otes:
47
Minnesota Title III-E Caregiver Questionnaire
A
ctivi
tie
s of Daily Living
[N
ote:
a
ssi
sta
nce with
tw
o
o
r
mor
e
A
DLs
o
r
n
eeds
su
per
vi
sion
f
or
res
pite
a
nd
s
upp.
se
rv
ice
s]
Can <NOP> walk around inside without
any help?
Ye
s
N
o
Can <NOP> bathe or shower without any
help?
Ye
s
N
o
Can <NOP> sit up or move around in
bed without any help?
Ye
s
N
o
Can <NOP> use the toilet without any
help?
Ye
s
N
o
Can <NOP> comb their hair, shave, wash
their face, or brush their teeth without
any help?
Ye
s
N
o
Can <NOP> dress without any help?
Ye
s
N
o
Can <NOP> get in and out of bed or
chair without any help?
Ye
s
N
o
Can <NOP> eat without any help?
Ye
s
N
o
Need for Supervision:
Does <NOP> have issues with memory, thinking, or the ability to make decisions that
result in the need for supervision?
Y
es
N
o
I
s <N
OP>
a Veteran?
Ye
s
No
I
f Ye
s,
do you or <NOP> receive any
Veteran’s benefits? Please describe:
Does
<N
OP
> receive assistance f
r
om
the
county or Medical Ass
istance
Ye
s
No
(i
e.,
does
NOP have a county w
orker?)
Wh
at h
eal
th problems or medical
conditions does
<
NO
P>
h
ave
tha
t need to be
ma
na
ged?
W
ha
t i
s your comfort level with
<NOP’s> medications or treatments?
A
re
you
s
a
ti
sfi
ed
w
i
t
h
th
e
a
mou
nt of information you have been given so far about
<N
OPs>
d
isease
or
c
ondit
ion (e.g., dementia, strok
e, Parkinson’s, etc.)? Or, d
o
yo
u
ha
ve
ques
tions that haven’t be
en addressed yet?
Ye
s
No
Ple
ase
de
scribe:
48
Minnesota Title III-E Caregiver Questionnaire
W
hat
type
s of UNPAID help or ca
re are you or <NOP> currently receiving from friends,
fa
mi
ly,
neighbors, people from c
hurch, or others in the community? (List person,
r
ela
tions
hip to CG or CR/
typ
e o
f hel
p/how often)
W
ho w
oul
d you call in an eme
rgency?
Do
you
hav
e plans in place for
caregiving in the event of an emergency or health care
cri
si
s
(e.g., who would help/type
of help, etc.)?
Do
you
hav
e concerns about <NOPs>
safety?
(e.
g., fa
ll
s, driving, cooking, wande
ring,
a
lco
hol
or drug use, fire
arms, self
-h
ar
m or
harm to you)
Y
es
N
o
Ple
ase
de
scribe:
A
re
th
ere issues that might ca
use you to consider a higher level of care for <NOP> or a
tra
nsi
ti
on into assisted living
or a nursing home? (e.g., worsening dementia, falls,
i
nconti
nence
,
yo
ur
phys
ical health, financia
l or emotional strain, etc.)
H
ave
you
and <NOP> done any p
lanning for the future? (Check all that apply)
(C
G
=
caregiver, NOP = old
er adult)
Adv
an
ced
healthcare directive
CG
N
OP
Pow
er
of a
ttorney
C
G
N
OP
A
w
il
l/trust/or estate pla
nning
CG
N
OP
G
ua
rdi
anship/Conservatorship
C
G
N
OP
N
otes:
49
Minnesota Title III-E Caregiver Questionnaire
P
art
III: C
aregiver Screen*
<Plea
se reflect on your experiences and rate your responses to the statements below. It will help us
gain a better understanding of your situation and how to work with you meet your needs>
1. A
s
a
result of assisting
<
NO
P>
,
to
wh
at extent have the followi
ng aspects of your
l
if
e ch
anged?
T
o w
hat
degree have your care
r
esp
onsi
bilities …
N
ot a
t
a
ll
A
l
itt
le
M
odera
tel
y
A
l
ot
A
gr
ea
t
dea
l
(a
)
Ca
use
d co
nflicts with your re
lative?
1
2
3
4
5
(b)
Dec
re
ased time you have to
your
sel
f?
1
2
3
4
5
(c)
Cr
eat
ed a feeling of hopelessn
ess?
1
2
3
4
5
(d)
G
ive
n your life more mean
ing?
1
2
3
4
5
(e)
Incr
eased the number of
unr
eason
ab
le requests made by yo
ur
r
ela
tive?
1
2
3
4
5
(f)
Ke
pt y
ou
fr
om
rec
reational
a
cti
vi
ties?
1
2
3
4
5
(g)
M
ade
you nervous?
1
2
3
4
5
(h)
Ma
de
you more satisfied with
your
r
ela
tions
hip?
1
2
3
4
5
(i
)
C
aused you to feel th
at your relative
ma
ke
s d
emands over and above w
hat
he/
she
n
eeds?
1
2
3
4
5
(j
)
C
aused
yo
ur
soci
al life to suffer?
1
2
3
4
5
(k)
Depr
esse
d you?
1
2
3
4
5
(l
)
G
iven you a sense of fulfi
llment?
1
2
3
4
5
(m)
M
ade
you feel you were being ta
ken
a
dva
nta
ge of by
yo
ur
rel
ative?
1
2
3
4
5
(n)
C
hange
d your routine?
1
2
3
4
5
(o)
M
ade
you
a
nxi
ous?
1
2
3
4
5
(p)
Left
yo
u feeling good?
1
2
3
4
5
(q)
I
ncrea
sed attempts by your rel
ative
to
ma
nipu
late you?
1
2
3
4
5
(r
)
Gi
ven you little time for
friends and
r
ela
tives
?
1
2
3
4
5
50
Minnesota Title III-E Caregiver Questionnaire
(s
)
C
aused you to worry?
1
2
3
4
5
(t)
M
ad
e you
en
joy
b
eing with your
r
ela
tive
more?
1
2
3
4
5
(u)
Le
ft yo
u with almost no time to
r
ela
x?
1
2
3
4
5
(v)
M
ade
you cherish your time
with
your
r
ela
tive?
1
2
3
4
5
*Mon
tg
om
ery Burden Scale. Sou
rce: Montgomery, R.J.V., E.F. Borgatta & M.L. Borgatta (2000)
Sum Baseline R Score = (a) ___ + (e) ___ + (i) ___ + (m) ___ + (q) ___ = ______
R Score = 13-25 High*; 8-12 Medium*; 5-7 Low
Sum Baseline O Score = (b) ___ + (f) ___ + (j) ___ + (n) ___ + (r) ___ + (u) ___= ______
O Score = 24-30 High*; 18-23 Medium*; 6-17 Low
Sum Baseline S Score = (c) ___ + (g) ___ + (k) ___ + (o) ___ + (s) ___ = ______
S Score = 17-25 High*; 12-16 Medium*; 5-11 Low
* Note: If scores are in the Medium or High range in ANY one of three burden measures, a referral for
a full TCARE® assessment is recommended.
CES-D Screen
2. Th
e fol
lowi
ng is a list of th
e ways you may have felt or behaved recently. For
ea
ch
s
ta
tement, indicate how ma
ny days you have felt this way
d
uri
n
g
the
p
as
t week
.
DU
RI
NG
THE PAST
W
EE
K:
Ra
rel
y
or
none
of
the
time
(les
s
tha
n
1
day)
Some
or
a
l
itt
le
of the
time
(1-2
day
s)
O
cca
si
onally
or
a
m
oderate
a
mt.
of t
ime
(3-4 da
ys
)
A
ll
o
f the
time
(5
-7
da
ys)
a. I
w
as
bother
ed by things
tha
t don’
t us
ually bother
me
1
2
3
4
b.
I
ha
d trouble keeping my
min
d o
n w
hat I was doing
1
2
3
4
c. I
f
elt
depre
ssed
1
2
3
4
d. I
f
elt t
hat everything I did
w
as
an
effort
1
2
3
4
e. I
f
elt
hopeful
about the
futur
e
4
3
2
1
f.
I
f
elt fearful
1
2
3
4
g.
M
y sl
eep was restless
1
2
3
4
h.
I
w
as happy
4
3
2
1
i.
I
fe
lt lonely
1
2
3
4
j.
I
cou
ld not “get going”
1
2
3
4
S
our
ce:
Center for Epidemiol
ogical Studies Depression Scale (CES-D)
51
Minnesota Title III-E Caregiver Questionnaire
S
um Bas
eli
ne CES-D Score: 26-40 Hi
gh*; 19-25 Medium*; 10-18 Low
* If scores medium or high a referral to primary care physician is recommended.
Part IV. Closing Questions
H
ow
much
time each week do you
have to yourself, to get things done, to socialize with
fa
mi
ly
/friends, relax, or
for other purposes?
W
hat
w
ould you do more of if you
had more time away from caring for
<N
OP>
?
A
fter
o
ur conversation today, w
hat do you think are the most immediate issues or
conc
erns
th
at need to be addressed
or that you need some assistance with? What
thi
ngs
wo
uld
yo
u l
ik
e us to address first
?
N
otes/
Add
itional Questions
52
Minnesota Title III-E Caregiver Questionnaire
Part
V. Sam
ple Caregive
r Plan
Name C
aregiver ID
Date of Plan
Initi
al
Foll
ow-
up
3
Mon
th
6
Mon
th
9
Mon
th
12
Mon
th
Goa
ls:
<At
least one goal should focus on caregive
r’s health>
G
oal
:
Desi
red
Outc
ome:
M
il
eston
e:
G
oal
:
Desi
red
O
utco
me:
M
i
l
eston
e:
G
oal
:
Desi
red
O
utco
me:
M
il
eston
e:
Ca
reg
iver
Consultant Responsibi
lity
Ca
reg
iver
Responsibility
Ca
reg
iver
Consultant
N
am
e
Si
gna
tur
e
Da
te
Ca
reg
iver
Name
Si
gna
tur
e
Da
te
53
Minnesota Title III-E Caregiver Questionnaire
L
ive Well At
Ho
me Rapid Screen
©
– Family Caregiver
Screen Date: ____________
1.
Does
<
n
am
e of
older person (NOP)>
need help from someone else
to
do
the
following?
a)
Wal
kin
g b) Getting out
of bed/chair c) Going to the bathroom
d
) Bat
hi
ng e) Dressing
f) E
ati
ng
I
f 2
o
r mo
r
e
cir
cled
SCO
RE
= 2
2.
Duri
ng
the
last 6 months, has <NOP>
had a fall that caused
i
njur
ies
or e
nga
ged
in behavior problems
such as wandering,
ver
ba
l
or physical disruption,
or other behaviors that require
su
per
vi
sion? Yes
No
NO
TE
:
“
In
ju
ries” means fracture o
r joint dislocation, head injuries resulting
i
n
lo
ss of consciousness and
hospitalization, joint injuries that led to
d
ec
re
ased activity, intern
al injuries that led to hospitalization OR 3 or more
o
f an
y f
alls
I
F YES c
ir
cled
SCO
RE
= 2
3.
Does
<N
OP
> have a family member
/friend give help when she/he
nee
ds
it?
Y
es
No
I
f N
O
circled
SCO
RE
=
2
4.
Do
you
fee
l overwhelmed or stress
ed because of the care you
pr
ovi
de
fo
r
<
NO
P>?
Yes No
I
f YES c
ir
cled
SCO
RE
=
2
5.
H
ave
you/<
NOP> thought about moving <NO
P> to other housing?
Ye
s
No
I
f YES,
wh
ere has <NOP> considered
moving to?
I
f a
nsw
ered NURSING HOME
or ASSISTED LIVING (i.e., Housing
W
ith
Serv
ices)
SCO
RE
= 2
6.
Does
<N
OP
> live alone?
Yes No
I
f YES c
ir
cled
SCO
RE
=
1
7.
Do
you
or
your family have
concerns about <NOP’s>
m
emory,
thi
nki
ng,
or ability to make
decisions?
I
f YES,
ar
e you: Very concerned
Somewhat concerned
I
f V
ERY
CONCERNED circled
SCO
RE
= 2
I
f SO
ME
WHAT CONCERNED circled
S
COR
E
= 1
T
OT
AL
SCORE (Sum of Scores For
Items 1 Through 7) =
Sc
ore
a
nd Risk Category
0
= N
o
Risk 1 = Low R
isk 2 = Moderate Risk 3 and
Hi
gh
er
= High Risk
54
Minnesota Title III-E Caregiver Questionnaire
Careg
iv
er Support - Initial
Assessment 1.2.2015 Page 1 of 6
Initial Assessment
Date of Initial Contact:___________ Name of Interviewer:________________ Date of Assessment:_________
Car
egive
r Na
me________________________________________
I
pref
er t
o be addressed as:___________________________________________
___________________________
Addr
ess:
_________________________________________________________________________________
Maili
ng a
ddre
ss (if different from above): _______________________________________________________
Da
yti
me phone
:________________ Alt phone:______________ Email:______________________________
W
hat i
s the best m
ethod to contact you?
Daytime phone Alt phone Email
Age
of Car
eg
iver: DOB__ /__ /____ or
Under 60
60-74
75-84 85+ Unknown
Ge
nder o
f Care
giver:
Male Female
Na
me
of In
dividual you provide care for
:____________________________________________________
Addr
ess (if livi
ng
in a different location): ______________________________________________________
L
en
gth o
f time you have been caring
for this person: ______________________________(in years and months)
How
many
hours do
you usually spend providing care for thi
s individual? _______
Day Week
W
ho else liv
es with
you, the primary caregiver?
__________________________________________________
How many adults 18 and over? ___________ How many younger than 18?_______________
Ar
e
you c
aring for anyone else? (
i.e. children, other adults, etc.)
No Yes_________________________
Ar
e ther
e a
ny communication issues, or do you nee
d an interpreter?
No Yes If yes, what is needed:
________________________________________________________________________________________
Who is
your
emergency contact? ______________________________________________________________
Who e
lse lives with the person you are caring for? ________________________________________________
Name:___________________________________ Relationship: ____________________________
Na
me:___________________________________ R
elations
hip: ____________________________
Name:___________________________________ Relationship: ____________________________
55
New Hampshire Initial Caregiver Assessment
C
areg
iv
er Support - Initial
Assessment 1.2.2015 Page 2 of 6
Veteran:
Has the individual you provide care for ever served in the military or armed forces?
Ye
s
No Don’t know
[If the answer is yes: “If you served in the active military, naval, or air services and are separated under any condition
other that dishonorable, you may qualify for VA healthcare benefits. Current and former members of the Reserves or
National Guard who were called to active duty (other than for training only) by a federal order and completed the full
period for which they were called or ordered to active duty may be eligible for VA healthcare as well.” ]
Notes: ____________________________________________________________________________________
__________________________________________________________________________________________
Ref
er
ral Source:
How
wer
e
you referred to the program?
Hospital Nursing or Rehab An individual
Home
Hea
lth A
gency/VNA
Adult Day Program Self-re
fe
rra
l
Alz
. Assoc
.
Other
S
ec
tion 1: C
aregiver Specific Informat
ion
Provi
di
ng t
he information below regardi
ng finances, ethnicity
and r
ace
is op
tional and is not required t
o determine
el
igi
bi
lity. Only responses without
personal identifying information will be shared. The U.S. Administration on Aging
re
quire
s t
he collection of thi
s information to gain a better understanding of the s
i
tuat
ions an
d needs of family
car
egi
vers
nationwide.
Annu
al I
ncom
e:
$0-2
0,
00
0
$
20
,0
01
-4
0,
00
0
$
40
,0
01
-6
0,
00
0
Ov
er
$6
0,000
Un
kn
ow
n
M
arit
al St
atus of Caregiver:
Nev
er
Mar
ried
Div
or
ced
Ma
rr
ied
L
iv
ing
with Partner
W
ido
wed
Un
kn
ow
n
E
thn
icity
of Caregiver:
His
pan
ic Or
igin
No
n
-H
isp
an
ic
Unk
no
wn
Rela
tio
nship
of Caregiver to Ca
re Recipient
:
(
The
ca
reg
iver is the
______of the care rec
ipient)
Ra
ce
of
Caregiver:
W
hite
Alon
e
B
lack/ A
fr
ican Amer.
Am
er.
I
nd./Alaska Nat.
A
sian
Nat.
Ha
wa
iian/Pacific Islander
So
me
oth
er race
T
wo
o
r more races
Un
kn
ow
n
Hu
sb
and
W
ife
P
artn
er
So
n/So
n
-in-L
aw
Dau
gh
ter/Da
ughter
-in-L
aw
Oth
er
Relati
ve
No
n
- R
elativ
e
Un
kn
ow
n
F
inan
cial
:
Ar
e
you c
urrently employed?
Yes ___ P
art-
time ___Fulltime
No
I
f not cur
re
ntly working, what is the main reason y
ou do not work?
Retired Disabled Unable to work temporarily
On layoff On family leave L
eft
job t
o provide care
Ar
e
you r
eceiving some type of pa
yment to provide care to this individual? **
Yes No
W
hich of the f
ollowing
best describes the financial situation of your household
?
Struggle to make ends meet Just enough to make ends meet, but no more
Meet our needs with occasional “extras” Generally comfortable
Ar
e ther
e medic
ations; supplies or treatments that eit
her you and/or the individual you are caring for should
have, but cannot afford to buy?
Yes No
I
n the ne
xt fe
w months, do you anticipate new expenses tha
t will be necessary in order to help keep the
individual you are caring for at home (renovations, wheelchair, or assistive equipment)?
Yes No
56
New Hampshire Initial Caregiver Assessment
Careg
iv
er Support - Initial
Assessment 1.2.2015 Page 3 of 6
Planning Ahead:
Are any of the following in place for the individual you provide care for? (Check any of the following that apply.)
A le
gal
gua
rdian
Yes
No
S
pec
ial POA
for health-care
Yes
No
DPOA f
or f
inanc
es
Yes
No
A livi
ng will
Yes
No
EMS
/DNR dire
cti
ves
Yes No
A f
uner
al pl
an
Yes No
A bur
ial plan
Yes No
Do
you n
ee
d assistance developing any
of the above?
Yes No _________________________________
Car
egivi
ng Exp
eriences & Strengths:
Freque
ntly there are positive aspects of caregiving. What are the most rewarding things for you about providing
care to the person you are caring for?___________________________________________________________
_________________________________________________________________________________________
Are
there
qualities and personal strengths tha
t you bring to your caregiving role? _______________________
_________________________________________________________________________________________
How
would y
ou sa
y your overall health is?
Poor Fair Good Very Good Excellent
Do
you
fee
l you have a good understanding of the indi
vidual’s condition? _________________________
Ar
e
you c
omfortable asking other people to be involved in or help in c
aregiving?
Yes No
__________________________________________________________________________________________
B
ack
Up Plan
:
I
s there
an
yone else assisting you with care
giving?
Yes No _________________________________
Do
you
cur
rently have anyone a
vailable to provide temporary emergency care when you are unable to?
Ye
s
No ___________________________________________________________________________
Are there challenges as a caregiver that you are concerned about?______________________________________
_________________________________________________________________________________________
Are there any circumstances that might prevent you from continuing to provide care at home within the next
three to six months? ________________________________________________________________________
__________________________________________________________________________________________
If for some reason you couldn’t continue to provide care is there someone who would take over as the primary
caregiver?_________________________________________________________________________________
Safety:
Do
you h
ave
any concerns about the safet
y of the individual you are caring for?
falling wa
nderin
g
Othe
r______________
________________________________________________
No concerns
Do e
ithe
r
you or
the individual you care for feel at risk of verbal abuse, physical abuse, neglect, self-
neglect or financial exploitation by another person? _______________________________________________
57
New Hampshire Initial Caregiver Assessment
C
areg
iv
er Support - Initial
Assessment 1.2.2015 Page 4 of 6
E
nvironm
en
tal:
(inte
rvie
wer
’s observations)
I
s there
safe
access to living areas (stairs, st
eps, doorways)?
Ye
s
No_________________________
I
s there
suffic
ient heating/air conditioning?
Ye
s
No_______________________________________
Ar
e ther
e c
oncerns about electrical / fire haz
ards?
Ye
s
No ___________
______________________
I
s there
prope
r egre
ss/escape plan in case of fi
re?
Ye
s
No ___________
______________________
Ar
e ther
e c
oncerns about yard work/snow remova
l?
Ye
s
No ________________________________
S
up
por
ts and Services:
Doe
s the individual
you
care for receive any servi
ces on a regular basis such as:
Homemaker
Home
Hea
lth or
VNA
VA
Choices for Inde
pende
nce
Other:_________________________
If yes, can you specify the health provider? _______________________________________
Self-Care:
Do
you
att
end a support group, educational, or tra
ining sessions?
Ye
s If
ye
s, is it helpful?
Ye
s
No
Note
s:________________________________________________________________________________
W
hat
you li
ke to see happen over the next six mo
nths to a year that would benefit you? (i.e. activities you may
have set aside that you used to enjoy)____________________________________________________
___________________________________________________________________________________________________________
Do you f
ee
l:
Nev
er
Ra
rely
So
me
-
t
im
es
Q
uite
O
ft
en
Nea
rly
Alw
ay
s
…that be
ca
use of the
time y
ou spend with
(c
are
recipi
ent’s
name
)
that
y
ou don’t hav
e e
nough time for yourself?
…st
ressed be
twee
n caring for
(c
are
recipi
ent’s name)
a
nd
tr
yin
g to
mee
t othe
r re
sponsibilities (work/family)?
…st
ra
ined w
hen
you are around
(c
ar
e
re
c
ipi
ent’s
name)
?
…unc
erta
in about wha
t to do about
(c
are re
cipi
ent’s
name
)
?
So
ur
ce: Z
arit 4-item Caregiver
Burden screen; Michel Bédard et.al., The Gerontologist 41:652-657 (2001)
S
ec
tion 2: C
are Recipient Specific Inf
ormation
Ge
nder o
f Care
Recipient:
Male
F
emale
Age
of Car
e R
e
c
ipient*
(
req
uir
ed
)
: DOB
__ /__ /____
Unde
r 60
60-74 75-84 85+
P
roviding the inf
ormatio
n below is helpful in determining other programs y
ou may be eligible for:
Ann
ual I
nc
ome:
$0-20,000 $20,001-40,000
$40,001-60,000 O
ver $60
,000
Unknow
n
Asse
ts:
(
Note:
exc
ludes primary home a
nd vehicle)
$0-5,000 $5,001-10,000
$10,001-20,000 $20,001-30,000
Ove
r $30,000
Unknow
n
58
New Hampshire Initial Caregiver Assessment
Careg
iv
er Support - Initial
Assessment 1.2.2015 Page 5 of 6
The Physical and Mental Status of the Individual Being Cared For:
In
stru
me
ntal Activities of Daily Living
(T
hi
s i
nformation is hel
pful in identifying potential community supports.)
Ye
s
No
A. Mea
l Pre
par
ation: Care recipient can prepa
re breakfast and light meals
B. Te
lephone: C
an use
telephone as necessary, e.g., a
ble to contact people in an emergency.
C. L
ig
ht Housewo
rk: can do light housework; washing dishes, dusting
(daily basis), making bed.
D. Mana
gin
g F
inances: Can manage own finances
; b
anking
; handling
checkbook; paying bills.
E. Medic
ati
on: Ca
n take medication on time with correct dose, without assis
tance.
F. Tr
ansporta
tion: Ne
e
ds t
ra
nsporta
ti
on a
nd/or e
sc
or
t
to m
e
dica
l, denta
l appointments, necessary
e
ngag
ements, or
oth
er a
cti
vities or needs
Ye
s No
Ha
s the individual be
en h
ospitalized or seen in the Emergency R
oom recently?
Defini
tio
ns:
Ind
ep
end
ent
:
c
an
accomplish with or without assist
ive devices
—N
o h
elp nee
ded.
Ne
eds
as
sistance
, o
r done
wit
h help: Individual involve
d in activity, but help
(i
nc
luding s
upervision, reminders,
a
nd/
or phy
sical “hands
-on
”
he
lp) is needed.
Dep
end
en
t
or do
ne
by ot
hers: Full performance of
the activity is done by others.
Note: a minimum of two ADL assists in columns # 2 or# 3 or cognitive impairment in categories 2 & 3 below are
required for eligibility for Title III-E funded services
Ac
tivities of
Daily Livi
ng
I
nd.
Asst.
De
p.
T
ran
sfe
rs:
How
individual moves to/
from:
bed, chair, wheelchair, or standing
Walk
ing/Mob
ility:
How
individual wa
lks or moves betwe
en locations in his/her
room a
nd other a
rea
s on same floor. If in wheelchair, self
-suf
ficienc
y on
ce in chair.
Dr
essi
ng:
How
individual puts
on, fa
stens, and takes off all items of clothing
E
atin
g:
How
individual e
ats and dr
inks (regardless of skill)
B
ath
ing /P
ersonal Hygiene:
How
individual take
s full
-bod
y b
ath/
shower, sponge
ba
th, and tra
nsfe
rs in/out of tub/shower; maintains personal hygiene, including
c
ombing
hair, b
rushing teeth, shaving, washing/ dry
ing face, & hands.
T
oile
t Use
:
How
individ
ual uses the toil
et; transfers on/off toilet, cleans self, adjusts
c
lothe
s; occa
sionally incontinent; frequently incontine
nt; or incontinent all of the
ti
me.
Cogni
tion:
Ye
s No
1. I
ndividua
l has a
Doctor’s diagnosis of Alzheimer’s disea
se or other type of
de
mentia.
2. I
t is no l
ong
er safe for the individual to be left alone.
3. The
individual is
no longe
r able to follow through with reminders or prompts.
How
many
hours e
ach day can the individual safely be
left alone? _____ Hours
_______________________________________________________________________________________
_______________________________________________________________________________________
59
New Hampshire Initial Caregiver Assessment
C
areg
iver Support - Initial
Assessment 1.2.2015 Page 6 of 6
Assis
tance
N
ote:
C
hec
k t
he
se
rv
ic
es the caregiver has used
, or
mi
ght
benefit from, if available.
H
av
e
Used
Co
ul
d
Use
H
av
e
Used
Co
ul
d
Use
N
ursi
ng ca
re at home
T
rai
ni
ng on providing care
Per
sonal
Car
e
C
ounsel
ing
H
ome
ma
ker services
T
rans
por
tation
C
hore s
erv
ices
H
ome M
odif
ications
A
dult
Day
O
ccupa
ti
onal Therapy
Fina
nci
al
/Medical assistance
A
ssi
st
ive Technology
Leg
al as
si
stance
Fuel
As
sis
tance
R
espi
te
-i
n home
H
ome Repai
rs
/Safety
R
espi
te
-Faci
li
ty
A
lt
er
native Housing
Suppor
t G
rou
p
V
et
eran’
s Benefits
H
ome Del
iv
ered Meals
O
ther
:
How
mig
ht the
se services be paid for?______________________________________________________
Would infor
mation on any of the following areas be helpful to you?
Medic
ar
e c
ounseling
Ye
s
No
L
ong
Te
rm Care Options
Ye
s
No
L
TC I
nsura
nce
Ye
s
No
P
harma
cy
Benefits
Ye
s
No
Educ
ati
on or tra
ining on how to care for yourself
as a caregiver?
Ye
s
No
Oppor
tunit
y to t
alk with a group of people in a similar situation, such as a support g
roup?
Ye
s
No
Ar
e ther
e a
ny other issues that you are concerne
d about that we didn’t cover?
_______________________________________________________________________________________
_______________________________________________________________________________________
***************************************************************************************
Notes:____________________________________________________________________________________
_________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
60
New Hampshire Initial Caregiver Assessment
61
Ohio Caregiver Assessment
62
Ohio Caregiver Assessment
63
Ohio Caregiver Assessment
64
Ohio Caregiver Assessment
Long Term Services and Supports Careg
iver Assessment
Client name: _________________
Caregiver name: _________________
Date: ______________
1. What
is
your
relationship with the person receiving care? ___________
_______________
2. How often are you consistent
ly providing care?
• Daily or multiple times daily Yes ____ No ____
• Several times per week Yes ____ No ____
• Once a week Yes ____ No ____
• Less than once a week Yes ____ No ____
How many hours per week do you provide care? __________________
How long have you been providing this care?_________________________
Do you have to travel to provide this care? If so, how far? Yes ____ No ____ _________________
3. What kind of care do you provide? How often do you provide this care?
• Personal Care Yes ____ No ____ _______________
• Housekeeping/Meal Prep Yes ____ No ____ _______________
• Transportation Yes ____ No ____ _______________
• Shopping/errands Yes ____ No ____ _______________
• Supervision for safety Yes ____ No ____ _______________
• Money management Yes ____ No ____ _______________
• Redirection, Cueing Yes ____ No ____ _______________
• Spending your personal funds Yes ____ No ____ _______________
• Other ________________________________________________________
4.
Does
anyone
share
the caregiver responsibilities with you? If yes
, who_________________________
5. Do your responsibiliti
es as a caregiver cause you to worry about:
• Work (lost time, decreasing hours, quitting work) Yes ____ No ____
• Family relationships/responsibilities
(kids sports activities, spousal relationships) Yes ____ No ____
• Financial matters both my loved one’s and my own Yes ____ No ____
• My own health, both physical and mental Yes ____ No ____
• Lost sleep and how it is affecting my well- being Yes ____ No ____
• What the fu
ture may bring and how I will manage it all Yes ____ No ____
• That I cannot provide the care that is necessary, Yes ____ No ____
65
Rhode Island Long Term Services and Supports Caregiver Assessment
• Behavioral issues of the person I c
are for. Yes ____ No ____
6. Does your role as a caregiver cause you emotional distress? Yes ____ No ____
7. What resources/services would best help you, in your role as a caregiver? _________________
( personal assistance for care recipient, respite, informational materials, support groups?)
8.
If
you
were
ever unable to continue to care for
____________________ is there
someone to take your place? Do you have a back-up plan? __________________
9. How would you rate your own health?
Excellent _____ Good _____ Fair _____
Poor ______ No response _______
Is it better or worse since you began your role as caregiver?______________________
10. Are you getting support in your role as a caregiver ? Yes ____ No ____
If yes, from whom? ______________________________
11.
Would you
like
information
about caregiver resources in addition to i
nformation about
services? __________________________
Caregiver chooses not to
participate _______.
66
Rhode Island Long Term Services and Supports Caregiver Assessment
67
South Carolina Eligibility for Title III-E Services Assessment
68
South Carolina Eligibility for Title III-E Services Assessment
69
South Carolina Eligibility for Title III-E Services Assessment
70
South Carolina Eligibility for Title III-E Services Assessment
SD
C
areg
iver Assmt
A.
CAR
EGI
VER/CARE RECEIVER
PROFILE
A.1.
CAR
EGI
VER INFORMATION
What i
s the CAREGIVER'S FIRST NAME?
What is the CAREGIVER'S MIDDLE INITIAL?
What is the CAREGIVER'S LAST NAME?
What is the CAREGIVER'S RESIDENTIAL STREET
ADDRESS?
What is the CAREGIVER'S MAILING ADDRESS, if different
from the residential street address?
Enter the CAREGIVER'S RESIDENTIAL CITY OR TOWN.
Enter the CAREGIVER'S STATE of residence.
Enter the CAREGIVER'S RESIDENTIAL ZIP CODE.
Enter the CAREGIVER'S TELEPHONE NUMBER, including
area code.
What is the CAREGIVER'S DATE OF BIRTH?
______/______/____________
What is the CAREGIVER'S GENDER?
1 - Male
2 - Female
What is the CAREGIVER'S ETHNICITY?
0 - Not Hispanic or Latino
1 - Hispanic or Latino
What is the CAREGIVER'S RACE?
1 - White
2 - American Indian or Alaska Native
3 - Asian
4 - Black or African American
5 - Native Hawaiian or Other Pacific Islander
6 - Other
What is the CAREGIVER'S MARITAL STATUS?
1 - Never Married
2 - Married
3 - Partner / Significant Other
4 - Widowed
5 - Separated
6 - Divorced
What is the CAREGIVER'S SOCIAL SECURITY NUMBER?
_________-_________-____________
Is the CAREGIVER'S income level below the national
POVERTY level?
0 - No
1 - Yes
A.2. CARE RECEIVER INFORMATION
What is the CARE RECEIVER'S FIRST NAME?
What is the CARE RECEIVER'S LAST NAME?
Enter the CARE RECEIVER'S RESIDENTIAL ADDRESS, if
different from caregiver.
Enter the TELEPHONE NUMBER of the CARE RECEIVER, if
different from caregiver.
Select the CARE RECEIVER'S current LIVING
ARRANGEMENT.
1 - Alone
2 - With spouse / partner only
3 - With spouse / partner and other(s)
4 - With child (not spouse / partner)
5 - With parent(s) or guardian(s)
6 - With sibling(s)
7 - With other relative(s)
8 - With non-relative(s)
SD Caregiver Assmt
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South Dakota Caregiver Assessment
Wha
t i
s
the CARE RECEIVER'S
DATE OF BIRTH?
______/______/____________
What
is
the
GENDER of the CARE RECE
IVER?
1 - Male
2 - Female
Describe the CARE RECEIVER'S MEDICAL CONDITIONS,
as reported by the caregiver.
Has the CARE RECEIVER been diagnosed with
ALZHEIMER'S DISEASE or other RELATED DEMENTIA?
0 - No
1 - Yes
Does the CARE RECEIVER'S household have any UNMET
NEEDS regarding ASSISTIVE DEVICES OR MEDICAL
EQUIPMENT?
0 - No
1 - Yes
Is the CARE RECEIVER eligible for or receiving any ASA
SERVICES?
0 - No
1 - Yes
A.3. CAREGIVING DETAILS
What is the relationship of the PRIMARY CAREGIVER TO
the CARE RECEIVER?
1 - Husband
2 - Wife
3 - Son/Son-in-law
4 - Daughter/Daughter-in-law
5 - Other Relative
6 - Non-Relative
Is the PRIMARY CAREGIVER PAID TO PROVIDE
ASSISTANCE to the Care Receiver?
0 - No
1 - Yes
How often does the PRIMARY CAREGIVER PROVIDE
ASSISTANCE to the care receiver?
1 - Several times during day
2 - Once daily
3 - Five or more times per week
4 - Less than 5 times per week
5 - Monthly
Does the PRIMARY CAREGIVER HELP the care receiver
with any ADL TASKS? If yes, list.
Does the PRIMARY CAREGIVER HELP the care receiver
with any IADL TASKS? If yes, list.
Does the PRIMARY CAREGIVER have any OTHER
CAREGIVING RESPONSIBILITIES? (Children, other
adults, etc.)
What is the PRIMARY CAREGIVER'S EMPLOYMENT
STATUS?
1 - Full-time
2 - Part-time
3 - Fully Retired
4 - Retired, works part-time
5 - Not Employed
6 - Other (List in Notes)
A.4. IMPACT OF CAREGIVING
Which of the following areas are a BURDEN to the
PRIMARY CAREGIVER as a result of providing care to the
care receiver?
1 - Emotional health
2 - Family responsibilities
3 - Finances
4 - Job
5 - Physical health
6 - Other (Describe in Notes)
Because of providing care to the care receiver, the
PRIMARY CAREGIVER FEELS that s/he (check all that
apply):
Does not have enough time for him/herself
Does not have enough privacy
Is unable to take care of the care receiver much longer
A.5. SECONDARY CAREGIVER
SD Caregiver Assmt
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South Dakota Caregiver Assessment
I
s
there a
SECONDARY CAREGIVER
who provides care on
a regul
ar
ba
sis?
0 - No
1 - Yes
Wha
t is the NAME of the SECONDARY CAREGIVER?
What is the RELATIONSHIP of the SECONDARY
CAREGIVER to the CARE RECEIVER?
1 - Husband
2 - Wife
3 - Son/Son-in law
4 - Daughter/Daughter-in-law
5 - Other Relative
6 - Non-Relative
7 - None Exists
A.6. COMMUNITY SUPPORTS
If the CAREGIVER PARTICIPATES in a SUPPORT OR
DISCUSSION GROUP, describe the group and frequency
of attendance.
Does the CAREGIVER have TROUBLE UNDERSTANDING
THE BEHAVIORS of the care receiver?
0 - No
1 - Sometimes
2 - Yes
Does the CAREGIVER NEED TRAINING to better
understand the diagnosis and how to better manage this
diagnosis?
0 - No
1 - Sometimes
2 - Yes
Is the CARE RECEIVER WILLING TO ACCEPT CARE FROM
OTHERS?
0 - No
1 - Yes
SD Caregiver Assmt
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South Dakota Caregiver Assessment
B
.
OU
TCOME
B O
UT
COME
Wha
t SERVICES
AND SUPPO
RT OPTIONS were discussed
with the caregiver TO MEET her/his CURRENT NEEDS?
Please check all that apply.
1 - Support groups
2 - Training to better understand medical
condition/behaviors
3 - Counseling
4 - Respite
5 - Supplemental Services (assistive device, incontinence
supplies, etc.)
6 - Chore Services
7 - Homemaker/Personal Care
8 - Nursing Services
9 - Home modification
What was the outcome of the assessment?
Eligible - Authorized Services
Eligible - Caregiver Refused Services
Ineligible for Services
Referred to Other Services
Date
Title :
Date
Title :
SD Caregiver Assmt
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South Dakota Caregiver Assessment
-
1 -
C
AREGIVER FORM 2010a
Car
egiver Assessment Instructions
El
igib
ility
The
person
receiving services un
der the
National Family Caregiver Support Program (NFCSP) is
the Caregiver. In this assessment Client refers to the Caregiver. Eligible Caregivers to receive
services under the NFCSP include:
Adult family members (18 or older) or other adult informal caregivers providing care to
individuals 60 years of age and older.
Adult family members (18 and older) or other adult informal caregivers providing care to
individuals of any age with Alzheimer’s disease and related disorders.
Grandparents and other relatives (not parents) 55 years of age and older providing care
to children 18 years of age and younger.
Grandparents and other relatives (not parents) 55 years of age and older providing care
to adults, age 19 to 59 years, with disabilities.
Fra
il G
uidelines
To
receive
Respite or Supplemental servi
ces u
nder the NFCSP, the care recipient must meet frail
guidelines. Frail means, with respect to an older individual in a State, that the older
in
dividual
is determined
to
be functionally impaired because the individual –
(
A) (i)
is unable to perform
at lea
st two activities of daily living without substantial
human assistance, including verbal reminding, physical cueing, or supervision; or
(ii) at the option of the State, is unable to perform at least three such activities
without such assistance; or
(B) due to cognitive or other mental impairment, requires substantial supervision
because the individual behaves in a manner that poses a serious health or safety hazard
to the individual or to another individual.
For the state of Tennessee, we have adopted (A)(i) having a minimum of two (2) ADL
limitations or (B) has a cognitive or other mental impairment that requires substantial
supervision to prevent harm to self or others.
Any of the five NFCSP service categories may be provided to grandparents, step-
grandparents, and other older relative caregiver caring for a child.
Rec
ord R
equirements
Fo
r the N
FCSP there must be at
least
two records linked in SAMS; one for the Caregiver and one
for the Care Recipient. This Caregiver assessment is to be completed on the Caregiver. A
separate record must be created for the Care Recipient, using the SAMS ILA 2010 assessment.
At a minimum, for the Care Recipient in the SAMS ILA 2010, the following sections must be
completed:
Section 0.A. – Client Identification
Section 2 – Functional Assessment
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Tennessee Caregiver Assessment Instructions
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2 -
I. Pr
ofil
e
I.A. Caregive
r Identification
16. What is
the clien
t’s social security numb
er (SSN)? – Enter the client’s social
secu
rity nu
mber.
If you have only c
ollected the last 4 digits of the social security
number, you should enter “0” for the 5 digits prior to the last 4 digits.
17. Enter th
e prim
ary lo
cal client identifier for
the client. - The client identifier
estab
lishes a
sing
le
file for each client for us
e in recording ALL services received
from aging network agencies from all providers. If this is a new client, a number
will be automatically generated from the client’s date of birth and the last four
digits of the Social Security number when the information is entered into the
computer database. This number will be the same, no matter where the client
receives services. It is critical that you ensure the accuracy of the numbers used
to
create
the Client ID. If the numbers are
incorrect, the client will appear as
two different people in the database. This will result in inaccurate counts of
individuals served by the various programs.
I.
B.
Caregiver Profil
e
5. What is
the care re
ceiver’s status? – This question
is used to determine if a
client
(caregiver)
is eligib
le to receive services
under the NFCSP. Mark the
appropriate status of the Care Receiver.
7. Do
es the clien
t ha
ve any other caregiving
responsibilities? – List any other
careg
iving r
esponsibilities that the client ma
y have. For instance, caring for
children or other adults who may not meet the eligibility criteria for the NFCSP;
however, the caregiver is providing them care.
8. Desc
ribe
any
significant changes
or events that have taken place in the client’s
life
durin
g the last six (6) months? – If
there have been changes, give brief
desc
ription
of those changes.
10. What c
ontac
ts/s
erv
ices/supportive inte
rventions have been provided for the
client?
– If th
e client is receiving services
through other programs to assist them
in
prov
iding
care to the care recipient, li
st what services they are receiving and
through which program they are receiving those services.
II
. Car
egi
ver Tasks
II.
A. Type of Service
1. Do
es the
client provide the care r
ecipient with personal care? – Mark the
app
ropria
te r
esponse. Personal care in
cludes help with bathing, dressing,
toileting, shampooing hair, feeding, and transferring in and out of bed.
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Tennessee Caregiver Assessment Instructions
- 3 -
2. D
oes the client help the care re
cipient with
housekeeping? – Mark the
ap
propriate response. Ho
usekeep
ing includes help with meal preparation,
laundry, dishes, sweeping, vacuuming, mopping, and dusting.
3. D
oes the client help the care recipient
manage
his/her money? – Mark the
ap
propriate response. Mon
ey m
anagement includes check writing, bank
transactions, paying bills, investigating billing errors, and making investments.
4. D
oes the
client help the care recipient
with shopping
and/or errands? – Mark
the
appropriate response. Sh
oppin
g/Errands includes shopping for food,
medicines, clothing, and personal items and running errands for the care
recipient.
5. D
oes the client help the care recipient with
taking medi
cation? – Mark the
ap
propriate response. Medi
cation
management includes dispensing
medications and supervising with taking medications.
6. D
oes the client provide the
care recip
ient with transportation? – Mark the
ap
prop
riate response. Transport
ation
includes transporting person for medical
appointments, shopping, recreational or educational activities, visiting family or
friends, and making arrangements for the person’s transportation needs.
7. D
oes the client provide the care recip
ient with o
ther assistance? – Mark the
ap
propriate response. Ask
the client whe
ther they provide any other assistance
that has not already been addressed to the care recipient and include in
comment section.
I
II. Impact of Caregiv
ing
I
II.A. Caregiver Challenges
I
nitial Assessmen
t – If this
is an initial assessment, you are trying to determine if
these
aspects of their lives have
suffered s
ince they began providing care for the
care recipient.
Rea
ssessment – If this is a reasses
sment,
you are trying to determine if these
asp
ects of their lives have co
ntinued
to suffer since they began receiving services.
Receiving services may not for some caregivers make things completely better;
however, you are trying to determine if receiving services have helped any with
their caregiving responsibilities.
If
there have been no cha
nges sin
ce the initial assessment, then talk about what
changes could be made to better help with their caregiving needs.
1. H
ow does the client rate his/her
health? –
Ask the client how their health is,
u
sing categories on the fo
rm. M
ake sure you record their opinion of how
they would rate their health. This could be an indication of their potential
to continue providing care.
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4 -
3. D
oes the
client feel that his/her
health
has suffered because of involvement
with
the care
recipient? – Health probl
ems
of the client could prevent the
caregi
ver fro
m continuing to pro
vide
care.
4. Does
the client fee
l that the care recipient affects
his/h
er relationship with
fam
ily m
embers/friends in a
negative
way? – The extent to which the client
fee
ls that their r
elationships with family
and
friends has suffered because of
them caring for the care recipient, can affect the amount of stress or
burnout a client may be dealing with. This may be because of not having
enough time to spend with family and friends away from the care recipient.
5. D
oes the clien
t feel that his/her social
life h
as suffered because s/he is
carin
g for
the care recipient? – The client
my
struggle with a diminished
so
cial life
and feel that because they
are
caring for the care recipient they
may not have the time to have a social life as they once did.
9. D
oes the clien
t feel angry when s/he
is arou
nd the client? – Client may feel
an
gry abo
ut the increased dependency
of
the care recipient and the many
demands on their time, energy, money, as well as other things.
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Tennessee Caregiver Assessment Instructions
Caregiver Form 2010a
I. Profile
I.A. Caregiver Identification
1. What is the date of the assessment?
______/______/____________
2. Specify the type of assessment, or the reason for the
assessment.
Initial assessment
Reassessment
3.
What is the name of the person conducting this
assessment?
4. What is the name of the agency the assessor works
for?
5.
What is the client's first name?
6. What is the client's last name?
7. What is the client's middle initial?
8. Enter the client's residential street address or Post
Office box.
9. Enter the client's residential city or town.
10. Enter the client's state of residence.
11. Enter the client's residential zip code.
12. Enter the client's mailing street address or Post
Office box.
13. Enter the client's mailing city or town.
14. Enter the client's mailing state.
15. Enter the client's mailing ZIP code.
16. What is the client's social security number (SSN)?
_________-_________-____________
17. Enter the primary local client identifier for the client.
18. Enter the client's telephone number.
19. Alternate telephone number for client
20. What is the client's gender?
Female
Male
21.
What is the client's date of birth?
______/______/____________
22. Enter the age of the client in years.
23. Select the client's current marital status.
Divorced
Legally Separated
Married
Single
Widowed
24. What is the client's primary caregiver's ethnicity?
Hispanic or Latino
Not Hispanic or Latino
Unknown
Caregiver Form 2010a
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Tennessee Caregiver Assessment
25. What is the client's race?
American Indian/Native Alaskan
Asian
Black/African American
Missing
Native Hawaiian/Other Pacific Islander
Non-Minority (White, non-Hispanic)
Other
White-Hispanic
26. Is the client currently employed?
Full time
Part time
No
I.B. Caregiver Profile
1.
What is the care recipient's last name?
2. What is the care recipient's first name?
3.
Does the client live with the care recipient?
No
Sometimes
Yes
4. What is the relationship of the client to the care
recipient?
Daughter/Daughter-in-law
Grandparent (60+)
Husband
Non-relative
Other elderly non-relative (55+)
Other elderly relative
Other relative
Relationship Missing
Son/Son-in law
Wife
5. What is the care recipient's status.
Alzheimer's disease or related disorder
Client elderly (60+)
Disabled (18 to 59)
Minor (18 and under)
6. How long has client provided most of the care?
Less than 6 months
6 to 12 months
1 to 2 years
2 to 5 years
5+ years
7. Does the client have any other caregiving
responsibilities? (Children, other adults, etc.)
8. Describe any significant changes or events that have
taken place in the client's life during the last six months.
9. Are there other persons who can assist the client
with the care recipient if the client is not available?
No
Yes
10. What contacts/services/supportive interventions
have been provided for the client?
11. Do others assist the client with the care recipient?
No
Yes
Caregiver Form 2010a
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Tennessee Caregiver Assessment
II. Caregiving Tasks
II.A. Type of Service
1. Does the primary client provide the care recipient
with personal care?
Yes
No
2. Does the client help the care recipient with
housekeeping?
Yes
No
3.
Does the client help the care recipient manage
his/her money?
Yes
No
4. Does the client help the care recipient with shopping
and/or errands?
Yes
No
5.
Does the client help the care recipient with taking
medication?
Yes
No
6. Does the client provide the care recipient with
transportation?
Yes
No
7. Does the client provide the care recipient with other
assistance?
Yes
No
8. If services were not in place, would there be
anything that would make it difficult for the client to
provide care?
Yes
No
9. How often does the care recipient receive assistance
from the client?
Monthly
Weekly
One to two times per week
Three or more times per week
Once daily
Several times during day
Several times during day and night
Caregiver Form 2010a
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Tennessee Caregiver Assessment
III. Impact of Caregiving
III.A. Caregiver Challenges
1. How does the client rate his/her health?
Excellent
Good
Fair
Poor
2. Does the client feel that s/he has lost control of
his/her life since the care recipient became ill?
Never
Rarely
Sometimes
Frequently
3.
Does the client feel that his/her health has suffered
because of involvement with the care recipient?
Never
Rarely
Sometimes
Frequently
4. Does the client feel that the care recipient affects
his/her relationship with family members/friends in a
negative way?
Never
Rarely
Sometimes
Frequently
5.
Does the client feel that his/her social life has
suffered because s/he is caring for the care recipient?
Never
Rarely
Sometimes
Frequently
6. Does the client feel that s/he doesn't have enough
privacy because of caring for the care recipient?
Never
Rarely
Sometimes
Frequently
7. Does the client feel that s/he does not have enough
time for him/herself because of the time spent caring for
the care recipient?
Never
Rarely
Sometimes
Frequently
8. Does the client feel stressed between caring for the
care recipient and trying to meet other responsibilities?
Never
Rarely
Sometimes
Frequently
9. Does the client feel angry when s/he is around the
care recipient?
Never
Rarely
Sometimes
Frequently
10. Does the client feel that s/he does not have enough
money to take care of the care recipient and pay for the
rest of his/her expenses?
Never
Rarely
Sometimes
Frequently
11. Overall, does the client feel burdened caring for the
care recipient?
Never
Rarely
Sometimes
Frequently
12. Indicate the behaviors the care recipient has
demonstrated at least one a week.
Delusional
Disruptive behavior
Getting lost/wandering
Impaired decision-making
Memory deficit
Physical aggression
Verbal disruption
Not applicable
Caregiver Form 2010a
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Tennessee Caregiver Assessment
Date
Title :
Date
Title :
Caregiver Form 2010a
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Tennessee Caregiver Assessment
DAAS Caregiver Assessment
What is your immediate need as a caregiver?
1. At the present time please rate your emotional health
Excellent
Good
Fair
Poor
If fair or poor, how does this affect you?
2. Overall, how stressed do you feel in caring for the care receiver?
Not
stressed
Somewhat
Very
stressed
3. Do you have an illness or any limitations that affect your ability to provide caregiving?
Yes
No
If yes, please explain:
4. Do you have any financial responsibilities related to the cost of care for the care receiver?
Yes
No
If yes, does this cause any problems for you?
Explain:
5. Are there medications, supplies or treatments that either you and/or the care receiver should have,
but cannot afford to buy?
Yes
No
If yes, please explain:
6. Is anyone available to provide respite (relief) when you are unable to provide care?
Yes
No
If yes, is such assistance available on short notice?
Explain:
Please list the other people who are available to assist with care and/or provide respite (relief) when you are unable to
provide care. These should be informal (non-paid) supports.
Name
Phone
Relationship to
care receiver
Help
Provided
7. Do you experience difficulties because of certain behaviors or
needs of the care receiver, such as:
Often
Sometimes
Rarely
Never
Inappropriate shouting/ Verbally aggressive
Sexually aggressive/Sexual gestures or other inappropriate behaviors
Physically aggressive
Memory problems or trouble understanding others
Wandering off
Repeating self
Uncooperative
In need of much attention
Other situations
How does this affect you?
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Utah Caregiver Assessment Form
It’s important that you acknowledge your own need for support, information and assistance.
Yes
No
8. Do you participate in a support or education group where you can discuss your feelings?
If Yes, what type of group/frequency of attendance?
If No, are you interested in participating in a support or education group?
☐
Yes
☐
No
9. Does the fact that where you live (rural, small town, suburban, or urban area) create any
problems with your caregiving role?
If yes, please explain
10. What additional skills and abilities do you need to perform the necessary tasks to provide care for the care receiver?
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Utah Caregiver Assessment Form
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Utah Caregiver Assessment Form
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Utah Caregiver Assessment Form
Client Signature Date
Case Manager Signature Date
Case
Manager Notes/Thoughts/Observations:
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Utah Caregiver Assessment Form
Best Practices
Advanced Directives Checklist
Note to Case Manager: Caregivers often have difficult decisions to make on behalf of their care receivers. Asking the following
questions regarding legal issues and end of life wishes can help people identify the issues that need to be addressed and communicated
with others. Just having advance directive forms filled out will not be effective if there hasn’t been informed, thoughtful reflection
about their wishes. It is also helpful if the caregiver is aware of these wishes and is informed about where these written
documents are
located before crisis occurs. Please che
ck any of the following that apply:
Yes
No
Do you have a legal guardian
Name: Phone #:
Do you have a power of attorney for finances?
Can you locate the information
Do you have Advance Health Care Directives?
Can you locate the information
Do you have a medical treatment plan?
Can you locate the information
Do you have Emergency Medical Services (EMS)/Do Not Resuscitate (DNR) directives?
Can you locate the information
Do you have a funeral plan?
Can you locate the information
Do you have a burial plan?
Can you locate the information
Case Manager Recommendations:
_
_
Case Manager Date
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Utah Caregiver Assessment Form
Case Managers: Please make extra copies of this form to leave with client. Discuss appropriate services and
resources with caregiver. Check the services/resources that would be most useful to them and which ones they would like
to receive if they were available.
If it were possible to have access to any of the following services/resources in your area, which ones would be most
useful in your caregiving role?
Case Manager Recommendations:
______________________________________ ____________________
Case Manager Date
Possible Services/Resources
CG
CR
Is service
available
Possible Services/Resources
CG
CR
Is service
available
General:
Long-Term Care:
Information about available
services
Help in considering options
Assistance in accessing services
Help with admitting to a facility
Counseling/Support/Training
Housing assistance/Assisted
living
Case management
Hospice services
In-Home Care/Assistance:
LTC insurance
Training for special tasks you do
Other Services/Resources:
Homemaker services
Prescription assistance
(financial)
OT/PT for care receiver
Nutrition counseling &
Supplements
ERS/Support for emergencies
MOW/Food pantry
Help in organizing services,
training or support workers
Information on adult protective
services
Specialist/Medical services
Link with your faith community
Respite Care/Socialization:
Transportation
In-home respite care
Legal/Financial
Overnight respite
Equipment/Home
modifications
Senior center
Information on
Medicaid/Medicare
Adult day center
Companion program/volunteers
Other (specify)
Other (specify)
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Utah Caregiver Assessment Form
Best Practices
OPTIONAL
FORM
Do you have any concerns about safety for your care receiver? ☐ Yes ☐ No
Does your living or housing arrangements cause any difficulties? ☐ Yes ☐ No
Safety and Home Modification Checklist: (please check all that apply) Please make extra copies of this form to leave
with client.
Bathroom:
___ Grab bars or safety rails for support when getting in/out of tub/shower
___ Apply non-slip strips on bathtub and shower floors
___ Use bathmats and rugs with non-skid backings
___ Use an adjustable-height shower seat rather than standing (if necessary)
___ Install an adjustable-height or handheld showerhead
___ Turn down the water temperature on the hot water heater to 120 degrees to prevent scalding
___ Consider a raised toilet seat or grab bar to make getting up and down easier
___ Avoid locking the bathroom door when bathing to allow quicker access if necessary
Bedroom:
___ Widen or clear pathways through the bedroom – arrange furniture to create open space
___ Make sure all electrical cords have been cleared from paths
___ Place smoke and carbon monoxide detectors outside of bedrooms on each level of the home
___ Keep a phone with a cord within easy reach of the bed
___ Post a list of emergency numbers near the phone
___ Secure rug edges with double-sided tape or remove scatter rugs
___ Make sure you can switch on a lamp before leaving bed to illuminate the path
___ Carry a cordless phone with you if you feel unstable when you get out of bed
___ Consider using risers to elevate your bed if it is too close to the floor and makes it difficult to get up
Kitchen:
___ Don’t wear loose sleeves when cooking
___ Use a timer when cooking or baking so you don’t forget that something is cooking
___ Consider a long handled dustpan/broom combination to reduce bending
___ If you use a rug on the floor in front of the sink, use a rubber-backed mat
___ If you can’t read the stove/oven knobs, investigate large-sized controls through vision support organizations
___ Install cupboard door handles that are easy to grasp;, such as D-type handles
___ Store frequently used items in easy-to-reach cabinets and on countertops
___ Increase kitchen lighting over task areas such as countertops, stove, and sink
___ Have a seated workspace available
___ Create a safe place to rest hot food immediately as you remove it from the microwave
Living Room and Throughout the Home
___ Increase lighting at entryways
___ Leave lights on if you walk through the house after dark or use motion sensor lighting fixtures
___ Change to lever-type door handles if knobs are difficult to grasp or manipulate
___ Install no-step, no-trip thresholds at doorways
___ Install peepholes on exterior doors that are the right height for the homeowner
___ Install handles and locks on all windows that are easy to grip at the right height
___ Make sure all railings are sturdy and that handrails are on both sides of all stairs
___ Secure all rug edges with double-sided tape or consider removing them
___ Create visual contrast in stairs risers with paint or tape if vision problems are a concern
___ Make sure homeowners can see and use climate controls for heating and air conditioning
Notes:
*This is only a partial list and all items will not apply to every client. Consider consulting with an occupational therapist to consider
each person’s environment. This list was created by members of the Occupational Therapy Association of California.
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Utah Caregiver Assessment Form
Best Practices
OPTIONAL
FORM
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Utah Caregiver Assessment Form
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Post Strain
Index
NAPIS/DAAS Caregiver Intake
TOTAL RISK SCORE
1. Agency:
2. Date of Intake:
3. Intake Worker:
4. How did you learn about our services?
5. Last Name:
6. First:
7. M.I.:
8. Preferred Name:
9. Street Address/PO Box:
10. Apartment/Unit#:
11. City:
12. County:
13. State: 14. Zip: 15. Telephone
(H):
(C):
(W):
16. Email: 17. Gender:
Male Female
18. DOB:
19. Alternate Contact Name: 20. Alternate Contact Telephone:
21. Medical Condition:
22. Current Living Arrangement:
Lives Alone
With others
Spouse/Partner
Spouse & child
Child/Grandchildren
23. Marital Status:
Single Married Widowed
Divorced Separated
24. Persons in family/household:
1 2 3
4 5 6
7 8 plus
25. Veteran: Yes No
If yes, have you applied for
Veterans’ assistance?
Yes No
26. Current employment status:
Full-time
Not Employed
Part-time
R
etired
Volunteer
27. Are you below poverty level?
________________________
Yes
No
Not Answered
28. Is funding for professional help a
concern?
Yes No
29. Primary language spoken at
home: _______________________
Do you need an interpreter?
Yes No
30. Ethnicity:
Hispanic or Latino
Not Hispanic or Latino
31. Race:
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Pacific Islander
White
32. Rural?
Yes No
33. What prompted your call?
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Utah Caregiver Intake Form
00000000
34. Length of time you have been a primary caregiver for this person:
35. In the last five weeks, have there been changes that have made your situation more difficult?
Describe changes?
Yes (1) No (0)
36. Will there be a change or temporary situation in the near future that will impact care?
Yes (1) No (0)
37. Are you the only person involved in the caregiving on a regular basis?
Yes (1)
No (0)
38. Do you have any of the following demands on your time and energy?
a. Employed full-time or part-time
Yes (1)
No (0)
b. Minor children at home
Yes (1)
No (0)
c. Caring for a person with a severe disability
Yes (1)
No (0)
d. Raising a grandchild
Yes (1)
No (0)
e. Raising a grandchild with a DD/MR diagnosis
Yes (1)
No (0)
f. Caring for a second care receiver
Yes (1) No (0)
g. Does the caregiver have significant memory impairment?
Yes (5) No (0)
h. Does the care receiver have significant memory impairment?
Yes (5)
No (0)
39. How stressed do you feel as a caregiver?
Very (2)
Somewhat (1)
Not at all (0)
40. Have you received respite or supplemental services from the UCSP in the last 12 months?
Yes (0)
No (10)
41. If yes, did you find alternative/replacement services to meet the care receiver’s needs when services
ended?
Yes (0)
No (10)
42. Is there an APS supported finding for abuse, neglect, or exploitation?
If Yes, date referral made:
Yes (5)
No (0)
43. Do you feel you are at risk for abuse, neglect, self-neglect, or exploitation? (no score)
Yes (0) No (0)
44. Is the care receiver at risk of abuse, neglect, self-neglect, or exploitation? (no score)
Yes (0)
No (0)
45. How many times per week do you get away from the caregiving situation
(not counting employment)?
Never (3)
1-3 (2) 4-6 (1) 7+ (0)
46. How many hours a week do you get away from the caregiving situation
(not counting employment)?
Never (3)
1-2 (2) 3-5 (1) 6-8 (0)
Total Scored Caregiver Questions
The Caregiver Strain Index
I am going to read a list of things that other people have found to be difficult. Would you tell me if any of these apply to you? (give examples)
1. Sleep is disturbed (e.g., because is in and out of bed or wanders around at night)
Yes (1)
No (0)
2. It is inconvenient (e.g., because helping takes so much time or it’s a long drive over to help)
Yes (1)
No (0)
3. It is a physical strain (e.g., because of lifting in and out of chair; effort or concentration is required)
Yes (1)
No (0)
4. It is confining (e.g., helping restrict free time or cannot go visiting)
Yes (1)
No (0)
5. There have been family adjustments (e.g., because helping has disrupted routine; there has been no privacy)
Yes (1)
No (0)
6. There have been changes in personal plans (e.g., had to turn down a job; could not go on vacation)
Yes (1)
No (0)
7. There have been other demands on my time (e.g., from other family members)
Yes (1) No (0)
8. There have been emotional adjustments (e.g., because of severe arguments)
Yes (1)
No (0)
9. Some behavior is upsetting (e.g., because of incontinence; has trouble remembering things; or
accuses people of taking things)
Yes (1)
No (0)
10. It is upsetting to find has changed so much from his/her former self (e.g., he/she is a different person
than he/she used to be)
Yes (1)
No (0)
11. There have been work adjustments (e.g., because of having to take time off)
Yes (1) No (0)
12. It is a financial strain
Yes (1)
No (0)
13. Feeling completely overwhelmed (e.g., because of worry about ; concerns about how you will manage)
Yes (1)
No (0)
Total Score (count yes responses. Any positive answer may indicate a need for intervention in that area. A score
of seven or higher indicates a high level of stress)
95
Utah Caregiver Intake Form
00000000
00000000
0000000000000000
0000000000000000
Caregiver Activity Levels (ADL’s)
During the past seven days, how would you rate your ability to perform
the following:
Independent
(0)
Supervision
(1)
Requires
Assistance (2)
Dependent
(3)
Bathing (include shower, full tub or sponge bath/exclude washing
back, or hair)?
Dressing?
Toilet use?
Ability to walk about in your own home?
Your ability to eat?
Your ability to transfer?
Subtotal:
TOTAL ADL SCORE
Caregiver Activity Levels (IADL’s)
During the past seven days, how would you rate your ability to perform
the following:
Independent
(0)
Supervision
(1)
Requires
Assistance (2)
Dependent
(3)
Meal preparation?
Manage medications?
Manage money?
Heavy housework?
Light housekeeping?
Shopping?
Transportation?
Use the telephone?
Subtotal:
TOTAL IADL SCORE
Care Receiver
Care Receiver Last Name:
Alternate Contact Name:
Care Receiver First Name:
Alternate Contact Phone:
DOB:
How did you learn about our services?
Address:
Medical Condition:
How are you related to the care receiver?
(I am their…)
Husband Wife Non-Relative
Daughter/Daughter-In-Law
Son/Son-In-Law
Grandparent
Grandparent Ra
ising a Grandchild
Other Elderly Non-Relative
Other Elderly Relative
Grandchild
Other
96
Utah Caregiver Intake Form
00000000
00000000
00000000
00000000
00000000
00000000
00000000
00000000
00000000
00000000
0000000000000000
0000000000000000
0000000000000000
0000000000000000
0000000000000000
Care Receiver Activity Levels (ADL’s)
During the past seven days, how would you rate your ability to perform
the following:
Independent
(0)
Supervision
(1)
Requires
Assistance (2)
Dependent
(3)
Bathing (include shower, full tub or sponge bath/exclude washing
back, or hair)?
Dressing?
Toilet use?
Ability to walk about in your own home?
Your ability to eat?
Your ability to transfer?
Subtotal:
TOTAL ADL SCORE
Care Receiver Activity Levels (IADL’s)
During the past seven days, how would you rate your ability to perform
the following:
Independent
(0)
Supervision
(1)
Requires
Assistance (2)
Dependent
(3)
Meal preparation?
Manage medications?
Manage money?
Heavy housework?
Light housekeeping?
Shopping?
Transportation?
Use the telephone?
Subtotal:
TOTAL IADL SCORE
Caregiver Questions
Score Range
Caregiver Strain Index
Low = 0-46
Caregiver ADLs
Moderate = 47-92
Caregiver IADLs
High = 93+
Care Receiver ADLs
Care Receiver IADLs
TOTAL RISK SCORE
Comments:
97
Utah Caregiver Intake Form
00000000
00000000
00000000
00000000
00000000
00000000
00000000
00000000
00000000
00000000
00000000
00000000
00000000
00000000
00000000
00000000
00000000
0000000000000000
0000000000000000
0000000000000000
0000000000000000
0000000000000000
0000000000000000
0000000000000000
0000000000000000
0000000000000000
0000000000000000
0000000000000000
0000000000000000
UAI Part A 1
VIRGINIA UNIFORM ASSESSMENT INSTRUMENT
Date
Screen:
/ /
Assessment:
/ /
Reassessment:
/ /
I
DENTIFICATION/
B
ACKGROUND
Name & Vital Information
Client Name
:
Client SSN:
(Last) (First) (Middle Initial)
Address:
(Street) (City) (State) (Zip Code)
Phone:
City/County Code:
Directions to House:
Pets?
Demographics
Birthdate:
/ /
Age:
Sex:
Male
0
Female
1
(Month) (Day) (Year)
Marital Status:
Married
0
Widowed
1
Separated
2
Divorced
3
Single
4
Unknown
9
Race: Education: Communication of Needs:
White 0 Less than High School 0 Verbally, English 0
Black/African American 1 Some High School 1 Verbally, Other Language 1
American Indian 2 High School Graduate 2 Specify:
Oriental/Asian 3 Some College 3 Sign Language / Gestures / Device 2
Alaskan Native 4 College Graduate 4 Does Not Communicate 3
Unknown 9
Unknown 9 Hearing Impaired?
Ethnic Origin:
Specify:
Primary Caregiver/Emergency Contact/Primary Physician
Name:
Relationship:
Address:
Phone:
(H) (W)
Name:
Relationship:
Address:
Phone:
(H) (W)
Name of Primary Physician:
Phone:
Address:
Initial Contact
Who called:
(Name) (Relation to Client) (Phone)
Presenting Problem/Diagnosis:
98
Virginia Uniform Assessment Instrument
UAI Part A 2
CLIENT NAME:
Client SSN:
Current Formal Services
Do you currently use any of the following types of services?
No
0
Yes
1
Check All Services That Apply
Provider/Frequency:
Adult Day Care
Adult Protective
Case Management
Chore/Companion/Homemaker
Congregate Meals/Senior Center
Financial Management/Counseling
Friendl
y
Visitor/Tele
p
hone Reassurance
Habilitation/Su
pp
orted Em
p
lo
y
ee
Home Delivered Meals
Home Health/Rehabilitation
Home Repairs/Weatherization
Housing
Legal
Mental Health (Inpatient/Outpatient)
Mental Retardation
Personal Care
Respite
Substance Abuse
Transportation
Vocational Rehab/Job Counseling
Other:
Financial Resources
Where are you on the scale for annual
(monthly) family income before taxes?
Does anyone cash your check, pay your bills or
manage your business?
$20,000 or More ($1,667 or More)
0
No
0
Yes
1
Names
$15,000 - 19,999 ($1,250 - $1,666)
1
Legal Guardian,
$11
,
000 - 14
,
999
(
$ 917 - $1
,
249
)
2
Power of Attorne
y
,
$ 9
,
500 - 10
,
999
(
$ 792 - $ 916
)
3
Re
p
resentative Pa
y
ee
,
$ 7
,
000 - 9
,
499
(
$ 583 - $ 791
)
4
Othe
r
,
$ 5
,
500 - 6
,
999
(
$ 458 - $ 582
)
5
$ 5
,
499 or Less
(
$ 457 or Less
)
6
Do
y
ou receive an
y
benefits or entitlements?
Unknown
9
No
0
Yes
1
N
umber in Famil
y
unit: Auxiliar
y
Gran
t
Food Stam
p
s
Optional: Total monthly family income:
Fuel Assistance
General Relief
Do
y
ou currentl
y
receive income from…?
State and Local Hos
p
italization
No
0
Yes
Optional: Amount
Subsidized Housin
g
Black Lun
g
,
Tax Relief
Pension
,
Social Security,
What types of health insurance do you have?
SSI / SSDI,
No
0
Yes
1
VA Benefits, Medicare, #
Wages / Salary, Medicaid, #
Other,
Pending: No 0 Yes 1
QMB/SLMB:
No 0 Yes 1
All Other Public / Private:
99
Virginia Uniform Assessment Instrument
UAI Part A 3
CLIENT NAME:
Client SSN:
Physical Environment
Where do you usually live? Does anyone live with you?
Alone
1
Spouse
2
Other
3
Names of Persons in Household
House: Own
0
House: Rent
1
House: Other
2
Apartment
3
Rented Room
4
Name of Provider
(Place)
Admission
Date
Provider Number
(If Applicable)
Adult Care Residence
50
Adult Foster
60
Nursing Facility
70
Mental Health/
Retardation Facilit
y
80
Other
90
Where you usually live, are there any problems?
No
0
Yes
1
Check All Problems That Apply
Barriers to Access
Electrical Hazards
Fire Hazards / No Smoke Alarm
Insufficient Heat / Air Conditioning
Insufficient Hot Water / Water
Lack of / Poor Toilet Facilities (Inside/Outside)
Lack of / Defective Stove, Refrigerator, Freezer
Lack of / Defective Washer / Dryer
Lack of / Poor Bathing Facilities
Structural Problems
Telephone Not Accessible
Unsafe Neighborhood
Unsafe / Poor Lighting
Unsanitary Conditions
Other:
Describe Problems:
100
Virginia Uniform Assessment Instrument
UAI Part A 4
CLIENT NAME:
Client SSN:
F
UNCTIONAL
S
TATUS
(Check only one block for each level of functioning)
ADLS
Needs
Help?
MH Only 10
Mechanical Help
D
HH Only 2
Human Help
D
MH & HH 3
D
Performed
by Others 40
D
Is Not
Performed 50
No
00
Yes
Supervision 1
Physical
Assistance 2
Supervision 1
Physical
Assistance 2
Bathing
Dressing
Toileting
Transferring
Spoon
Fed 1
Syringe/
Tube Fed 2
Fed by
IV 3
Eating / Feeding
Continence
Needs
Help?
Incontinent
Less than weekly 1
External Device/
Indwelling/
Ostomy
Self care 2
D
Incontinent
Weekly or more 3
D
External
Device
Not self care 4
D
Indwelling
Catheter
Not self care 5
D
Ostomy
Not self care 6
No
00
Yes
Bowel
Bladder
Comments:
Ambulation
Needs
Help?
MH Only 10
Mechanical Help
D
HH Only 2
Human Help
D
MH & HH 3
D
Performed
by Others 40
D
Is Not
Performed 50
No
00
Yes
Supervision 1
Physical
Assistance 2
Supervision 1
Physical
Assistance 2
Walking
Wheeling
Stairclimbing
Confined
Moves About
Confined
Does Not Move About
Mobility
IADLS
Needs
Help?
No
0
D
Yes
1
Meal Preparation
Housekeeping
Laundry
Money Management
Transportation
Comments:
Shopping
Outcome: Is this a short assessment?
Using Phone
No, Continue with Section 0
Yes, Service Referrals 1
Yes, No Service Referrals 2
Home Maintenance
Screener:
Agency:
101
Virginia Uniform Assessment Instrument
UAI Part B 5
CLIENT NAME:
Client SSN:
P
HYSICAL
H
EALTH
A
SSESSMENT
Professional Visits/Medical Admissions
Doctor’s Name(s) (List all) Phone Date of Last Visit Reason for Last Visit
Admission: In the past 12 months have, you been admitted to a . . . for medical or rehabilitation reasons?
No
0
Yes
1
Name of Place Admit Date Length of Stay/Reason
Hospital
Nursing Facility
Adult Care Residence
Do you have any advance directives such as . . . (Who has it…Where is it…)?
No
0
Yes
1
Location
Living Will,
Durable Power of Attorney for Health Care,
Other,
Diagnoses & Medication Profile
Do you have any current medical problems, or a known or suspected diagnosis of mental
retardation or related conditions, such as . . . (Refer to the list of diagnoses)?
Current Diagnoses Date of Onset
Enter Codes for 3 Major, Active Diagnoses:
None
00
DX1 DX2 DX3
Current Medications Dose, Frequency, Route Reason(s) Prescribed
(Include Over-the-Counter)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Total No. of Medications:
(If 0, skip to Sensory Function)
Total No. of Tranquilizer/Psychotropic Drugs:
Do you have any problems with medicine(s)…? How do you take your medications?
No
0
Yes
1
Without assistance 0
Adverse reactions / allergies Administered / monitored by lay person 1
Cost of medication Administered / monitored by professional
Getting to the pharmacy nursing staff 2
Taking them as instructed / prescribed Describe help:
Understanding directions / schedule Name of helper:
Diagnoses:
Alcoholism/Substance Abuse (01)
Blood-Related Problems (02)
Cancer (03)
Cardiovascular Problems
Circulation (04)
Heart Trouble (05)
High Blood Pressure (06)
Other Cardiovascular Problems (07)
Dementia
Alzheimer’s (08)
Non-Alzheimer’s (09)
Developmental Disabilities
Mental Retardation (10)
Related Conditions
Autism (11)
Cerebral Palsy (12)
Epilepsy (13)
Friedreich’s Ataxia (14)
Multiple Sclerosis (15)
Muscular Dystrophy (16)
Spina Bifida (17)
Digestive/Liver/Gall Bladder (18)
Endocrine (Gland) Problems
Diabetes (19)
Other Endocrine Problems (20)
Eye Disorders (21)
Immune System Disorders (22)
Muscular/Skeletal
Arthritis/Rheumatoid Arthritis (23)
Osteoporosis (24)
Other Muscular/Skeletal Problems (25)
Neurological Problems
Brain Trauma/Injury (26)
Spinal Cord Injury (27)
Stroke (28)
Other Neurological Problems (29)
Psychiatric Problems
Anxiety Disorder (30)
Bipolar (31)
Major Depression (32)
Personality Disorder (33)
Schizophrenia (34)
Other Psychiatric Problems (35)
Respiratory Problems
Black Lung (36)
COPD (37)
Pneumonia (38)
Other Respiratory Problems (39)
Urinary/Reproductive Problems
Renal Failure (40)
Other Urinary/Reproductive Problems (41)
All Other Problems (42)
102
Virginia Uniform Assessment Instrument
UAI Part B 6
CLIENT NAME:
Client SSN:
Sensory Functions
How is your vision, hearing, and speech?
No Impairment
0
Impairment
Record Date of Onset/Type of Impairment
Complete Loss
3
Date of Last Exam
Compensation
1
No Compensation
2
Vision
Hearing
Speech
Physical Status
Joint Motion: How is your ability to move your arms, fingers and legs?
Within normal limits or instability corrected
0
Limited motion
1
Instability uncorrected or immobile
2
Have you ever broken or dislocated any bones . . . Ever had an amputation or lost any limbs . . . Lost voluntary movement of
any part of your body?
Fractures/Dislocations Missing Limbs Paralysis/Paresis
None 000
None 000
None 000
Hip Fracture 1
Finger(s)/Toe(s) 1
Partial 1
Other Broken Bone(s) 2
Arm(s) 2
Total 2
Dislocation(s) 3
Leg(s) 3 Describe:
Combination 4 Combination 4
Previous Rehab Program? Previous Rehab Program? Previous Rehab Program?
No/Not Completed 1 No/Not Completed 1 No/Not Completed 1
Yes 2 Yes 2 Yes 2
Date of Fracture/Dislocation? Date of Amputation? Onset of Paralysis?
1 Year or Less 1
1 Year or Less 1
1 Year or Less 1
More than 1 Year 2
More than 1 Year 2
More than 1 Year 2
Nutrition
Height:
Weight:
Recent Weight Gain/Loss:
No
0
Yes
1
(inches) (lbs.)
Describe:
Are you on any special diet(s) for medical reasons? Do you have any problems that make it hard to eat?
None 0
No
0
Yes
1
Low Fat / Cholesterol 1
Food Allergies
No / Low Salt 2
Inadequate Food / Fluid Intake
No / Low Sugar 3
Nausea / Vomiting / Diarrhea
Combination / Other 4
Problems Eating Certain Foods
Problems Following Special Diets
Do you take dietary supplements?
Problems Swallowing
None 0
Taste Problems
Occasionally 1
Tooth or Mouth Problems
Daily, Not Primary Source 2
Other:
Daily, Primary Source 3
Daily, Sole Source 4
103
Virginia Uniform Assessment Instrument
UAI Part B 7
CLIENT NAME:
Client SSN:
Current Medical Services
Rehabilitation Therapies: Do you get any therapy
prescribed by a doctor, such as …?
Special Medical Procedures: Do you receive any special
nursing care, such as …?
No
0
Yes
1
Frequency No
0
Yes
1
Site, Type, Frequency
Occupational
Bowel/Bladder Training
Physical
Dialysis
Reality/Remotivation
Dressing/Wound Care
Respiratory
Eyecare
Speech
Glucose/Blood Sugar
Other
Infections/IV Therapy
Oxygen
Do you have pressure ulcers?
Radiation/Chemotherapy
None 0
Location/Size
Restraints (Physical/Chemical)
Stage I 1
ROM Exercise
Stage II 2
Trach Care/Suctioning
Stage III 3
Ventilator
Stage IV 4
Other:
Medical/Nursing Needs
Based on client’s overall condition, assessor should evaluate medical and/or nursing needs.
Are there ongoing medical/nursing needs?
No
0
Yes
1
If yes, describe ongoing medical/nursing needs:
1. Evidence of medical instability.
2. Need for observation/assessment to prevent destabilization.
3. Complexity created by multiple medical conditions.
4. Why client’s condition requires a physician, RN, or trained nurse’s aide to oversee care on a daily basis.
Comments:
Optional: Physician’s Signature: Date:
Others: Date:
(Signature/Title)
104
Virginia Uniform Assessment Instrument
UAI Part B 8
CLIENT NAME:
Client SSN:
P
SYCHO
-S
OCIAL
A
SSESSMENT
Cognitive Function
Orientation (Note: Information in italics is optional and can be used to give a MMSE Score in the box to the right.)
Optional: MMSE Score
Person: Please tell me your full name (so that I can make sure our record is correct).
Place: Where are we now (state, country, town, street/route number, street name/box number)?
Give the client 1 point for each correct response.
(5)
Time: Would you tell me the date today (year, season, date, day, month)?
Oriented 0
Spheres affected:
(5)
Disoriented – Some spheres, some of the time 1
Disoriented – Some spheres, all the time 2
Disoriented – All spheres, some of the time 3
Disoriented – All spheres, all of the time 4
Comatose 5
Recall/Memory/Judgment
Recall: I am going to say three words, and I want you to repeat them after I am done
(House, Bus, Dog). Ask the client to repeat them. Give the client 1 point
for each correct response on the first trial. Repeat up to 6 trials until client
can name all 3 words. Tell the client to hold them in his mind because you
will ask him again in a minute or so what they are.
(3)
Attention/
Concentration: Spell the word “WORLD”. Then ask the client to spell it backwards.
Give 1 point for each correctly placed letter (DLROW).
(5)
Short-Term: Ask the client to recall the 3 words he was to remember.
Total:
Long-Term: When were you born (What is your date of birth)?
Judgment: If you needed help at night, what would you do?
No
0
Yes
1
Note: Score of 14
Short-Term Memory Loss?
or below implies
Long-Term Memory Loss?
cognitive impairment
Judgment Problems?
Behavior Pattern
Does the client ever wander without purpose (trespass, get lost, go into traffic, etc.) or become agitated and abusive?
Appropriate 0
Wandering / Passive – Less than weekly 1
Wandering / Passive – Weekly or more 2
Abusive / Aggressive / Disruptive – Less than weekly 3
Abusive / Aggressive / Disruptive – Weekly or more 4
Comatose 5
Type of inappropriate behavior: Source of Information:
Life Stressors
Are there any stressful events that currently affect your life, such as . . . ?
No
0
Yes
1
No
0
Yes
1
No
0
Yes
1
Change in work/employment
Financial problems
Victim of a crime
Death of someone close
Major illness - family/friend
Failing health
Family conflict
Recent move/relocation
Other:
105
Virginia Uniform Assessment Instrument
UAI Part B 9
CLIENT NAME:
Client SSN:
Emotional Status
In the past month, how often did you . . . ?
Rarely/
Never
0
Some of
the Time
1
Often
2
Most of
the Time
3
Unable to
Assess
9
Feel anxious or worry constantly about things?
Feel irritable, have crying spells or get upset over little things?
Feel alone and that you don’t have anyone to talk to?
Feel like you didn’t want to be around other people?
Feel afraid that something bad was going to happen to you
and/or feel that others were trying to take things from you
or trying to harm you?
Feel sad or hopeless?
Feel that life is not worth living … or think of taking your life?
See or hear things that other people did not see or hear?
Believe that you have special powers that others do not have?
Have problems falling or staying asleep?
Have problems with your appetite … that is, eat too much or
too little?
Comments:
Social Status
Are there some things that you do that you especially enjoy?
No
0
Yes
1
Describe
Solitary Activities,
With Friends / Family,
With Groups / Clubs,
Religious Activities,
How often do you talk with your children family or friends either during a visit or over the phone?
Children Other Family Friends / Neighbors
No Children 0
No Other Family 0
No Friends/Neighbors 0
Daily 1
Daily 1
Daily 1
Weekly 2
Weekly 2
Weekly 2
Monthly 3
Monthly 3
Monthly 3
Less than Monthly 4
Less than Monthly 4
Less than Monthly 4
Never 5
Never 5
Never 5
Are you satisfied with how often you see or hear from your children, other family and/or friends?
No 0 Yes 1
106
Virginia Uniform Assessment Instrument
UAI Part B 10
CLIENT NAME:
Client SSN:
Hospitalization/Alcohol – Drug Use
Have you been hospitalized or received inpatient/outpatient treatment in the last 2 years for nerves, emotional/mental health,
alcohol or substance abuse problems?
No
0
Yes
1
Name of Place Admit Date Length of Stay/Reason
Do (did) you ever drink alcoholic beverages?
Do (did) you ever use non-prescription, mood altering
substances?
Never 0
Never 0
At one time, but no longer 1
At one time, but no longer 1
Currently 2
Currently 2
How much: How much:
How often:
How often:
If the client has never used alcohol or other non-prescription, mood altering substances, skip to the tobacco question.
Have you, or someone close to you, ever
been concerned about your use of
alcohol/other mood altering substances?
Do (did) you ever use alcohol/other
mood-altering substances with …
Do (did) you ever use alcohol/other
mood-altering substances to help you …
No
0
Yes
1
No
0
Yes
1
No
0
Yes
1
Prescription drugs? Sleep?
Describe concerns:
OTC medicine? Relax?
Other substances? Get more energy?
Relieve worries?
Describe what and how often:
Relieve physical pain?
Describe what and how often:
Do (did) you ever smoke or use tobacco products?
Never 0
At one time, but no longer 1
Currently 2
How much:
How often:
Is there anything we have not talked about that you would like to discuss?
107
Virginia Uniform Assessment Instrument
UAI Part B 11
CLIENT NAME:
Client SSN:
A
SSESSMENT
S
UMMARY
Indicators of Adult Abuse and Neglect: While completing the assessment, if you suspect abuse, neglect or exploitation, you are required by
Virginia law, Section 63.1-55.3, to report this to the local Department of Social Services, Adult Protective Services.
Caregiver Assessment
Does the client have an informal caregiver?
No
0
(Skip to Section on Preferences)
Yes
1
Where does the caregiver live?
With client 0
Separate residence, close proximity 1
Separate residence, over 1 hour away 2
Is the caregiver’s help . . .
Adequate to meet the client’s needs? 0
Not adequate to meet the client’s needs? 1
Has providing care to client become a burden for the caregiver?
Not at all 0
Somewhat 1
Very much 2
Describe any problems with continued caregiving:
Preferences
Client’s preference for receiving needed care:
Family/Representative’s preference for client’s care:
Physician’s comments (if applicable):
108
Virginia Uniform Assessment Instrument
UAI Part B 12
CLIENT NAME:
Client SSN:
Client Case Summary
Unmet Needs
No
0
Yes
1
(Check All That Apply)
No
0
Yes
1
(Check All That Apply)
Finances Assistive Devices / Medical Equipment
Home / Physical Environment Medical Care / Health
ADLS Nutrition
IADLS Cognitive / Emotional
Caregiver Support
Assessment Completed By:
Assessor’s Name Signature Agency/Provider Name Provider #
Section(s)
Completed
Optional: Case assigned to: Code #:
109
Virginia Uniform Assessment Instrument
VT
D
AI
L Full ILA11
V
T
DAIL
Independent Living Assessment (
Full ILA)
0A.
Cov
er S
heet: INDIVIDUAL IDENT
IFICATION
0. ILA is being completed for which (DAIL) program?
A - Adult day
B - ASP
C - HASS
D - Homemaker
E - Medicaid Waiver (Choices for Care)
F - AAA services (NAPIS)
G - Other
H - Dementia Respite
1. Date of assessment?
______/______/____________
2. Unique ID# for client.
3.a. Client's last name?
3.b. Client's first name?
3.c. Client's middle initial?
4. Client's telephone number.
5. Client's Social Security Number?
_________-_________-____________
6. Client's date of birth?
______/______/____________
calculated age at assessment
7. Client's gender?
M - Male
F - Female
T - Transgendered
8.a. Client's mailing street address or Post Office box.
8.b. Client's mailing city or town.
8.c. Client's mailing state.
8.d. Client's mailing ZIP code.
9.a. Residential street address or Post Office box.
9.b. Residential city or town.
9.c. Client's state of residence.
9.d. Client's residential zip code.
0B. Cover Sheet: ASSESSOR INFORMATION
1. Agency the assessor works for?
2. ILA completed by? (name of assessor)
0C. Cover Sheet: EMERGENCY CONTACT INFORMATION
1.a. Primary Emergency contact name?
1.a.1. Primary Emergency contact relationship?
1.b. Primary Emergency contact home phone?
1.b.1. Primary Emergency contact work phone?
1.c. Street address of Primary Emergency Contact?
VT DAIL Full ILA11
S:\Omnia\Assessment Forms\VT DAIL Full NSI-ILA 2011.afm Page 1 of 29
3/27/2015
110
Vermont DAIL Independent Living Assessment
1
.d
. Ci
ty or town of Primary E
mergency Contact?
1.
e.
Sta
te of Primary Emergency Conta
ct?
1.f. Zip code for Promary Emergency contact?
1.g. Emergency Contact #1's relationship to client
2.a. Name of Emergency Contact 2?
2.b. Phone number of the client's Emergency Contact
#2?
2.c. Street address or P.O box of the client's emergency
contact #2?
2.d. City or town of the client's emergency contact #2?
2.e. State of client's Emergency Contact #2?
2.f. ZIP code of the client's emergency contact #2?
3.a. Client's primary care physician?
3.b. Phone number for the client's primary care
physician?
4. Does the client know what to do if there is an
emergency?
A - Yes
B - No
5
. In the
case of an emergency, wo
uld the client be able
to
get out o
f his/her home safely?
A
- Y
es
B -
No
6
. In the
case of an emergency, wo
uld the client be able
to
summon hel
p to his/her home?
A
-
Y
es
B -
No
7
. Do
es the client require
immediate a
ssistance from
Emergency Services in a man-made or natural disaster?
A - Yes
B - No
8. Who is the client's provider for emergency response
services?
9. Comments regarding Emergency Response
0D. Cover Sheet: DIRECTIONS TO CLIENT'S HOME
Directions to client's home.
1A. Intake: ASSESSMENT INFORMATION
1. Type of assessment
A - Initial assessment
B - Reassessment
C - Update for Significant change in status assessment
2
. Are there c
ommunication barriers for
which you need
as
sista
nce?
A
- Y
es
B -
No
3. I
f yes, type o
f assi
stance?
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4
. Cl
ient'
s primary language.
E
-
En
gli
sh
L - American S
ign Language
F - French
B - Bosnian
G - German
I - Italian
S - Spanish
P - Polish
T - Portuguese
M - Romanian
R - Russian
C - Other Chinese
V - Vietnamese
O - Other
4.a. Please specify or describe the client's primary
language that is other than in the list.
1B. Intake: LEGAL REPRESENTATIVE
1.a. Does the client have an agent with Power of
Attorney?
A - Yes
B - No
1.b. Name of client's agent with Power of Attorney?
1.c. Work phone number of the client's agent with Power
of Attorney.
1
.d. H
ome phone number of the client's
agent with Power
of
Attorney.
2
.a. Do
es the client have a Repres
entative Payee?
A
- Ye
s
B - No
2.b. Name of c
lient's Representative Payee?
2.c. Work phone number of the client's Representative
Payee.
2.d. Home phone number of the client's Representative
Payee.
3.a. Does the client have a Legal Guardian?
A - Yes
B - No
3.b. Name of the client's Legal Guardian?
3.c. Work phone number of the client's Legal Guardian.
3.d. Home phone number of the client's Legal Guardian.
4.a. Does client have Advanced Directives for health care?
A - Yes
B - No
4.b. Name of agent for client's Advanced Directives?
4.c. Work phone number of the client's agent for
Advanced Directives?
4.d. Home phone number of the client's agent for
Advanced Directives.
4.e. If no Advanced Directives, was information provided
about Advanced Directives?
A - Yes
B - No
1C. Intake: DEMOGRAPHICS
1. What is client's marital status?
A - Single
B - Married
C - Civil union
D - Widowed
E - Separated
F - Divorced
G - Unknown
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2
a.
What
is client's race/ethnic
ity?
A
-
Non
-Minority (White
, non-Hispanic)
B - African American
C - Asian/Pacific Islander (incl. Hawaiian)
D - American Indian/Native Alaskan
E - Hispanic Origin
F - Unknown
G - Other
2.G.Other. Enter the client's self-described ethnic
background if OTHER
2b. What is the client's Hispanic or Latino ethnicity?
Choose one.
A - Not Hispanic or Latino
B - Hispanic or Latino
C - Unknown
2c. What is the client's race? Choose multiple.
A - Non-Minority (White, non-Hispanic)
B - Black/African American
C - Asian
D - American Indian/Native Alaskan
E - White-Hispanic
F - Unknown
H - Native Hawaiian/Other Pacific Islander
G - Other
3. What type of residence do you live in?
A - House
B - Mobile home
C - Private apartment
D - Private apartment in senior housing
E - Assisted Living (AL/RC with 24 hour supervision)
F - Residential care home
G - Nursing home
H - Unknown
I - Other
4. Client's Living arrangement? Who do you live with?
A - Lives Alone
B - Lives with others
C - Dont know
5. Does the client reside in a rural area? Must answer
yes for NAPIS
A - Yes
B - No
1D. Intake: HEALTH RELATED QUESTIONS: General
1
. Were yo
u admitted to a hospital
for any reason in the
la
st 30
days?
A
-
Y
es
B -
No
2
.
In the past year,
how ma
ny times have you stayed
overnight in a hospital?
A - Not at all
B - Once
C - 2 or 3 times
D - More than 3 times
3. Have you ever stayed in a nursing home, residential
care home, or other institution? (including Brandon
Training School and Vermont state Hospital)
A - Yes
B - No
4. Have you fallen in the past three months?
A - Yes
B - No
5. Do you use a walker or four prong cane (or
equivalent), at least some of the time, to get around?
A - Yes
B - No
6. Do you use a wheelchair, at least some of the time,
to get around?
A - Yes
B - No
7. In the past month how many days a week have you
usually gone out of the house/building where you live?
A - Two or more days a week
B - One day a week or less
8. Do you need assistance obtaining or repairing any of
the following? (Check all that apply)
A - Eyeglasses
B - Cane or walker
C - Wheelchair
D - Assistive feeding devices
E - Assistive dressing devices
F - Hearing aid
G - Dentures
H - Ramp
I - Doorways widened
J - Kitchen/bathroom modifications
K - Other
L - None of the above
1E. Intake: THE NSI DETERMINE Your Nutritional Health
Checklist
1. Have you made any changes in lifelong eating habits
because of health problems?
A - Yes (Score = 2)
B - No
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2
. Do
y
ou eat fewer than 2 meals
per day?
A
-
Ye
s (Score = 3)
B - No
3.
Do you eat fewer than five (5) servings (1/2 cup
each) of fruits or vegetables every day?
A - Yes (Score = 1)
B - No
4
. Do
y
ou eat fewer than two servi
ngs of dairy products
(s
uch
as
milk, yogurt, or chees
e) every day?
A
- Y
es (Score = 1)
B -
No
5.
Do
you have trouble eating
due to problems with
chewing/swallowing?
A - Yes (Score = 2)
B - No
6. Do you sometimes not have enough money to buy
food?
A - Yes (Score = 4)
B - No
7. Do you eat alone most of the time?
A - Yes (Score = 1)
B - No
8. Do you take 3 or more different prescribed or
over-the-counter drugs per day?
A - Yes (Score = 1)
B - No
9. Without wanting to, have you lost or gained 10
pounds or more in the past 6 months?
A - Yes (Score = 2)
B - No
L - Yes, lost 10 pounds or more
G - Yes, gained 10 pounds or more
10. Are there times when you are not always physically
able to shop, cook and/or feed yourself (or to get
someone to do it for you)?
A - Yes (Score = 2)
B - No
11. Do you have 3 or more drinks of beer, liquor or wine
almost every day?
A - Yes (Score = 2)
B - No
What is the client's nutritional risk score?
12. Total score of Nutritional Risk Questions. Add the
scores for all Yes answers for questions 1 to 11 in the
Nutritional Health Checklist.
12.a. Is the client at a high nutritional risk level? Must
answer for NAPIS.
Don't know
No
Yes
NUTRITIONAL RISK SCORE means:
0-2 GOOD: Recheck your score in 6 months
3-5 MODERATE RISK: Recheck your score in 3 months
6+ HIGH RISK : May need to talk to Doctor or
Dietitian Enter any comments......
13. Is the client interested in talking to a nutritionist
about food intake and diet needs?
A - Yes
B - No
C - Don't know
14. How many prescription medications do you take?
15. About how tall are you in inches without your shoes?
16. About how much do you weigh in pounds without
your shoes?
Calculated Body Mass Index
1F. Intake: SERVICE PROGRAM CHECKLIST
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1
.a
. I
s the client participating
in any of the following
serv
ic
es
or programs?
A - Home
health aide (LNA)
B - Homemaker program
C - Hospice
D - Nursing (RN)
E - Social work services
F1 - Physical therapy
F2 - Occupational therapy
F3 - Speech therapy
G - Adult Day Health Services/Day Health Rehab
H - Attendant Services Program
I - Developmental Disability Services
J - Choices for Care Medicaid Waiver (HB/ERC)
K - Medicaid High-Tech services
L - Traumatic Brain Injury waiver
M - USDA Commodity Supplemental Food Program
N - Congregate meals (Sr. Center)
O - Emergency Food Shelf/Pantry
P - Home Delivered Meals
Q - Senior Farmer's Market Nutrition Program
Q1 - Nutritional Counseling
R - AAA Case Management
S - Community Action Program (CAP)
T - Community Mental Health services
U - Dementia Respite grant/NFCSP Grant
V - Eldercare Clinician
W - Job counseling/vocational rehabilitation
X - Office of Public Guardian
Y - Senior companion
Z - VCIL peer counseling
AA - Association for the Blind and Visually Impaired
BB - Legal Aid services
CC - Assistive Community Care Services (ACCS)
DD - Housing and Supportive Services (HASS)
EE - Section 8 voucher, housing
FF - Subsidized housing
GG - ANFC
HH - Essential Persons program
II - Food Stamps
JJ - Fuel Assistance
KK - General Assistance program
LL - Medicaid
MM - QMB/SLMB
NN - Telephone Lifeline
OO - VHAP
PP - VPharm (VHAP Pharmacy)
RR - Emergency Response System
SS - SSI
TT - Veterans benefits
UU - Weatherization
VV - Assistive Devices
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1
.b
. Do
es the client want to appl
y for any of the following
serv
ic
es
or programs?
A
- H
ome health aide
(LNA)
B -
Hom
emaker program
C - Ho
spice
D - Nursing (RN)
E - Social Work Services
F1 - Physical therapy
F2 - Occupational therapy
F3 - Speech therapy
G - Adult day services/Day Health Rehab
H - Attendant Services Program
I - Developmental Disability Services
J - Choices for Care Medicaid Waiver (HB/ERC)
K - Medicaid High-Tech Services
L - Traumatic Brain Injury Waiver
M - USDA Commodity Supplemental Food Program
N - Congregate Meals (Sr. Center)
O - Emergency Food Shelf/Pantry
P - Home Delivered Meals
Q - Senior Farmer's Market Nutrition Program
Q1 - Nutrition Counseling
R - AAA Case Management
S - Community Action Program
T - Community Mental Health Services
U - Dementia Respite Grant Program/NFCSP Grant
V - Eldercare Clinician
W - Job counseling/vocational rehabilitation
X - Office of Public Guardian
Y - Senior companion
Z - VCIL peer counseling
AA - Association for the Blind and Visually Impaired
BB - Legal Aid services
CC - Assistive Community Care Services (ACCS)
DD - Housing and Supportive Services (HASS)
EE - Section 8 Voucher (Housing Choice)
FF - Subsidized Housing
GG - ANFC
HH - Essential Persons program
II - Food stamps
JJ - Fuel Assistance
KK - General Assistance Program
LL - Medicaid
MM - QMB/SLMB
NN - Telephone Lifeline
OO - VHAP
PP - VPharm (VHAP Pharmacy)
RR - Emergency Response System
SS - SSI
TT - Veterans Benefits
UU - Weatherization
VV - Assistive Devices
1G. intake: POVERTY LEVEL ASSESSMENT
1. Are you currently employed?
A - Yes
B - No
2. How many people reside in the client's household,
including the client?
3. HOUSEHOLD INCOME: Estimate the total client's
HOUSEHOLD gross income per month?
$
4. CLIENT INCOME: Specify the client's monthly income.
$
5. Is the client's income level below the national
poverty level?
A - Yes
B - No
C - Don't know
Current year used for Federal Poverty Level
Poverty Income test current yr Client only
Percent of poverty for client current year (if less than 1.0
client is in poverty)
Poverty Income Test current yr household
Percent of Poverty for household Current year
Food Stamp Eligibility Current Year
Food Stamp Monthly Gross Income Limit
Food Stamp Income Test current yr household
Food Stamp Eligible (1 = yes)
Fuel Assistance Current Year
Fuel Assistance Seasonal Percent Poverty Test
Fuel Assistance Crisis Percent Poverty Test
Fuel Assistance Shareheat Percent Poverty Test
Fuel Household Income - Fuel 60+ deduction
Fuel Percent of Poverty household current yr
1H1. Intake: FINANCIAL RESOURCES: Monthly Income
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1
.a
.1
. Client's monthly soci
al security income.
$
1.
a.
2.
Monthly social securi
ty income of the client's
spouse
$
1.b.1. Client's monthly SSI income
$
1.b.2. Monthly SSI income of the client's spouse
$
1.c.1. Client's monthly retirement/pension income
$
1.c.2. Monthly retirement/pension income of the
client's spouse.
$
1.d.1. Client's monthly interest income.
$
1.d.2. Monthly interest income of the client's spouse.
$
1.e.1. Client's monthly VA benefits income.
$
1.e.2. Monthly VA benefits income of the client's
spouse.
$
1.f.1. Client's monthly wage/salary/earnings income
$
1.f.2. Monthly wage/salary/earnings income of the
client's spouse.
$
1.g.1. Client's other monthly income.
$
1.g.2. Other monthly income of the client's spouse.
$
1H2. Intake: FINANCIAL RESOURCES: Monthly Expenses
2.a. Client's monthly rent.
$
2.a2. Client's monthly mortgage.
$
2.b. Client's monthly property tax.
$
2.c. Client's monthly heat bill.
$
2.d. Client's monthly utilities bill.
$
2.e. Client's monthly house insurance cost.
$
2.f. Client's monthly telephone bill.
$
2.g. Monthly amount of medical expense the client incurs.
$
2.h.1. Describe other expenses
2.h.2. Monthly amount of other expenses?
$
1H3. Intake: FINANCIAL RESOURCES: Savings/Assets
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3
.a
.1
. What is the name of the ba
nk/institution where
the c
li
ent's
checking account is
located?
3.a.2. What is the client's checking account number?
3.a.3. What is the client's checking account balance?
$
3.b.1. What is the name of the bank/institution where
the client's primary savings account is located?
3.b.2. What is the client's primary savings account
number?
3.b.3. What is the client's primary savings account
balance?
$
3.c.1. What is the source of Stocks/Bonds/CDs
resources?
3.c.2. What is the amount from Stock/Bonds/CDs?
$
3.d.1. What is the name of the bank/institution where
the client's burial account is located?
3.d.2. What is the client's burial account number?
3.d.3. What is the client's burial account balance?
$
3.e.1. What is the name of the client's primary life
insurance company?
3.e.2. What is the client's primary life insurance policy
number?
3.e.3. What is the face value of the client's primary life
insurance policy?
$
3.e.4. What is the cash surrender value of the client's
primary life insurance policy?
$
3.f.1. What is the name of the bank/institution where
the client's other account #1 is located?
3.f.2. What is the client's other account number #1?
3.f.3. What is the client's other account #1 balance?
$
3.g.1. What is the name of the bank/institution where
the client's other account #2 is located?
3.g.2. What is the client's other account number #2?
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3
.g
.3
. What
is
the
client's other ac
count #2
balance?
$
1H4. Intake: FINANCIAL RESOURCES: Health Insurance
4.a.1. Does the client have Medicare A health
insurance?
A - Yes
B - No
4.a.2. What is the effective date of the client's
Medicare A policy?
______/______/____________
4.a.3. What is the client's Medicare A policy number?
4.a.4. What is the client's monthly Medicare A
premium? (enter 0 if no premium)
$
4.b.1. Does the client have Medicare B health
insurance?
A - Yes
B - No
4.b.2. What is the effective date of the client's
Medicare B policy?
______/______/____________
4.b.3. What is the client's Medicare B policy number?
4.b.4. What is the client's monthly Medicare B
premium? (Enter 0 if no premium)
$
4.c.1. Does the client have Medicare C health
insurance?
A - Yes
B - No
4.c.2. What is the name of the client's Medicare C
plan?
4.c.3. What is the effective date of the client's
Medicare C policy?
______/______/____________
4.c.4. What is the client's Medicare C plan premium?
(Enter 0 if no premium)
$
4.d.1. Does the client have Medicare D health
insurance?
A - Yes
B - No
4.d.2. What is the name of the client's Medicare D
plan?
4.d.3. What is the effective date of the client's
Medicare D plan?
______/______/____________
4.d.4. What is the client's Medicare D plan premium?
(Enter 0 if no premium)
$
4.e.1. Does the client have Medigap health insurance?
A - Yes
B - No
4.e.2. What is the name of the client's Medigap health
insurer?
4.e.3. What is the client's monthly Medigap premium?
(Enter 0 if no premium)
$
4.f.1. Does the client have LTC health insurance?
A - Yes
B - No
4.f.2. What is the name of the client's LTC health
insurer?
4.f.3. What is the client's monthly LTC premium?
(Enter 0 if no premium)
$
4.g.1. Does the client have other health insurance?
A - Yes
B - No
C - Don't know
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4
.g
.2
. Enter the
name
of
the client's other
health
insura
nce carrier, if applicable.
4.g.3. What is the client's other monthly premium?
(Enter 0 if no premium)
$
4.h.1. Does the client have VPharm insurance?
A - Yes
B - No
4.h.2. What is the effective date of VPharm insurance?
______/______/____________
1H5. Intake: FINANCIAL RESOURCES: Comments
Comment on the client's current financial situation.
1H6. intake: FINANCIAL CALCULATIONS
Calculated Total Client Income
Calculated Client + Spouse Income
Calculated Monthly Insurance Expenses
Calculated Monthly non-insurance Expenses
Calculated Total Monthly Expenses
Calculated Total Income - Expenses
Calculated total assets balance
1I. Intake: "SELF NEGLECT", ABUSE, NEGLECT, AND
EXPLOITATION SCREENING
1. Is the client refusing services and putting him/her
self or others at risk of harm?
A - Yes
B - No
C - Information unavailable
2. Does the client exhibit dangerous behaviors that
could potentially put him/her self or others at risk of
harm?
A - Yes
B - No
C - Information unavailable
3
. Can the
Client make clear, informed
decisions about
his
/her ca
re needs (Regardless of the c
onsequence of the
decision)?
A
- Y
es
B -
No
C -
Informati
on una
vailable
4. Is there evidence (Observed or reported) of
suspected abuse, neglect or exploitation of the client by
another person?
A - Yes
B - No
C - Information unavailable
5. ASSESSOR ACTION: If answer to 1 or 2 is yes refer
clients >60 to Area Agency on Aging or if <60 to Adult
Protective Services. If 3 is yes, consider a negotiated risk
contract. if 4 is yes mandated reportes must file a report
of abuse...Enter comments..
2. Supportive Assistance
1. Who is the primary unpaid person who usually helps
the client?
A - Spouse or significant other
B - Daughter or son
C - Other family member
D - Friend, neighbor or community member
E - None
2. How often does the client receive help from his/her
primary unpaid caregiver?
A - Several times during day and night
B - Several times during day
C - Once daily
F - Less often than weekly
D - Three or more times per week
E - One to two times per week
G - Unknown
3. What type of help does the client's primary unpaid
caregiver provide?
A - ADL assistance
B - IADL assistance
C - Environmental support
D - Psychosocial support
E - Medical care
F - Financial help
G - Health care
H - Unknown
4. What is the name of the client's primary unpaid
caregiver?
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5
. Wha
t i
s the relationship of the pri
mary unpaid
ca
regiv
er to
the client?
6. What is the pho
ne number of the client's primary
unpaid caregiver?
7. What is the address of the client's primary unpaid
caregiver?
8. In your role as a caregiver do you need assistance in
any of the following areas?
A - Job
B - Finances
C - Family responsibilities
D - Physical health
E - Emotional health
F - Other
9. ASSESSOR ACTION:
If caregiver indicates factors in question #8 , discuss
options for family support services and make appropriate
referrals. Consider completing "Caregiver
Self-Assessment Questionaire"
... Enter any Comments on Client's Support System.
3A. Living Environment: LIVING ENVIRONMENT HAZARDS
1. Do any structural barriers make it difficult for you to
get around your home?
A - Stairs inside home - must be used
B - Stairs inside home - optionally used
C - Stairs outside
D - Narrow or obstructed doorways
E - Other
F - None
2. Do any of the following safety issues exist in your
home?
A - Inadequate floor, roof or windows
B - Inadequate/insufficient lighting
C - Unsafe gas/electric appliance
D - Inadequate heating
E - Inadequate cooling
F - Lack of fire safety devices
G - Flooring or carpeting problems
H - Inadequate stair railings
I - Improperly stored hazardous materials
J - Lead-based paint
K - Other
L - None of the above
2.a. Other safety hazards found in the client's current
place of residence.
3
. Do a
ny of the following sa
nitation issues exist in your
home?
A
- No
running water
B -
C
on
taminated water
C
- No toileting facilities
D - Outdoor toileting facilities
E - Inadequate sewage disposal
F - Inadequate/improper food storage
G - No food refrigeration
H - No cooking facilities
I - Insects/rodents present
J - No trash pickup
K - Cluttered/soiled living area
L - Other
M - None
3.a. Other sanitation hazards found in the client's current
place of residence.
4A. Emotional/Behavior/Cognitive Status: EMOTIONAL
WELL BEING
1. Have you been anxious a lot or bothered by nerves?
A - Yes
B - No
C - No response
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2
. H
av
e you felt down, depressed,
hopeless or helpless?
A
-
Ye
s
B - No
C - No response
3
. Are you bothered by little interest or pleasure in
doing things?
A - Yes
B - No
C - No response
4. Have you felt satisfied with your life?
A - Yes
B - No
C - No response
5. Have you had a change in sleeping patterns?
A - Yes
B - No
C - No response
6. Have you had a change in appetite?
A - Yes
B - No
C - No response
7. Have you thought about harming yourself?
A - Yes
B - No
C - No response
8. Do you have a plan for harming yourself?
A - Yes
B - No
9. Do you have the means for carrying out the plan for
harming yourself?
A - Yes
B - No
10. Do you intend to carry out the plan to harm yourself?
A - Yes
B - No
11. Have you harmed yourself before?
A - Yes
B - No
12. Are you currently being treated for a psychiatric
problem?
A - Yes
B - No
13. Where are you receiving psychiatric services?
A - At home
B - In the community
C - Both at home and in the community
14. If any question in this section was answered yes,
what action did the assessor take?
15.READ. You have just expressed concerns about
your emotional health. There are some resources and
services that might be helpful; if you are interested I will
initiate a referral or help you refer yourself
...............Enter comments if any...
4B. Emotional/Behavior/Cognitive Status: COGNITIVE
STATUS
1. What was the client's response when asked, 'What
year is it?'
A - Correct answer
B - Incorrect answer
C - No response
2. What was the client's response when asked, 'What
month is it?'
A - Correct answer
B - Incorrect answer
C - No response
3. What was the client's response when asked, 'What
day of the week is it?'
A - Correct answer
B - Incorrect answer
C - No response
4. Select the choice that most accurately describes the
client's memory and use of information.
A - No difficulty remembering
B - Minimal difficulty remembering (cueing 1-3/day)
C - Difficulty remembering (cueing 4+/day)
D - Cannot remember
5. Select the choice that most accurately describes the
client's global confusion.
A - Appropriately responsive to environment
B - Nocturnal confusion on awakening
C - Periodic confusion in daytime
D - Nearly always confused
6. Indicate the client's ability to speak and verbally
express him or herself.
A - Speaks normally (No observable impairment)
B - Minimal or minor difficulty
C - Moderate difficulty (can only carry simple
conversations)
D - Unable to express basic needs
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7
. Wha
t i
s the client's abili
ty to make decisions
regardi
ng ta
sk
s of daily life?
A -
Independent - decisions consistent/reasonable
B - Modified independence - some difficulty in new
situations only
C - Moderately impaired - decisions poor;
cues/supervision
D - Severely impaired - never/rarely makes decisions
ASSESSOR ACTION:
If EMOTIONAL HEALTH issues refer to Area Agency on
Aging/Eldercare Clinician or Community mental health
If COGNITION issues refer to Doctor or Mental Health
professional
4C. Emotional/Behavior/Cognitive Status: BEHAVIORAL
STATUS
1.a. How often does the client get lost or wander?
0 - Never
1 - Less than daily
2 - Daily
1.b. In the last 7 days was the client's wandering
behavior alterable?
0 - Behavior not present OR behavior easily altered
1 - Behavior was not easily altered
2.a. How often is the client verbally abusive?
0 - Never
1 - Less than daily
2 - Daily
2.b. In the last 7 days was the client's verbally abusive
behavior alterable?
0 - Behavior not present OR behavior easily altered
1 - Behavior was not easily altered
3a. How often is the client physically abusive to others?
0 - Never
1 - Less than daily
2 - Daily
3.b. In the last 7 days was the client's physically abusive
behavior alterable?
0 - Behavior not present OR behavior easily altered
1 - Behavior was not easily altered
4.a. How often does the client exhibit socially
inappropriate/disruptive behavior? (e.g. disruptive
sounds, noisiness, screaming, self-abusive acts, etc.)
0 - Never
1 - Less than daily
2 - Daily
4.b. In the last 7 days was the client's socially
inappropriate or disruptive behavior symptoms alterable?
0 - Behavior not present OR behavior easily altered
1 - Behavior was not easily altered
5.a. How often did the client display symptoms of
resisting care (resisted taking medications -injections,
ADL assistance, or eating) in the last 7 days?
0 - Never
1 - Less than daily
2 - Daily
5.b. In the last 7 days was the client's resistance to care
symptoms alterable?
0 - Behavior not present OR behavior easily altered
1 - Behavior was not easily altered
Comment on behaviors
5A. Health Assessment (for CFC must be completed by
RN/LPN): DIAGNOSIS/CONDITIONS/TREATMENTS
1. Describe the client's primary diagnoses.
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2
. I
ndic
ate which of the follow
ing conditions/diagnoses
the c
li
ent c
urrently has.
A
- E
NDOCRINE-Diabetes
B
-
ENDO
CRINE-Hyperthyroidism
C
- ENDOCRINE-Hypothyroidism
D - HEART-Arteriosclerotic heart disease (ASHD)
E - HEART--Cardiac dysrhythmias
F - HEART--Congestive heart failure
G - HEART--Deep vein thrombosis
H - HEART--Hypertension
I - HEART--Hypotension
J - HEART--Peripheral vascular disease
K - HEART-Other cardiovascular disease
L - MUSCULOSKELETAL-Arthritis/rheumatic disease/gout
M - MUSCULOSKELETAL-Hip fracture
N - MUSCULOSKELETAL-Missing limb (e.g., amputation)
O - MUSCULOSKELETAL-Osteoporosis
P - MUSCULOSKELETAL-Pathological bone fracture
Q - NEUROLOGICAL-Alzheimer's disease
R - NEUROLOGICAL-Aphasia
S - NEUROLOGICAL-Cerebral palsy
T - NEUROLOGICAL-Stroke
U - NEUROLOGICAL - Non-Alzheimer's dementia
V - NEUROLOGICAL-Hemiplegia/Hemiparesis
W - NEUROLOGICAL-Multiple sclerosis
X - NEUROLOGICAL-Paraplegia
Y - NEUROLOGICAL-Parkinson's disease
Z - NEUROLOGICAL-Quadriplegia
AA - NEUROLOGICAL-Seizure disorder
BB - NEUROLOGICAL-Transient ischemic attack (TIA)
CC - NEUROLOGICAL-Traumatic brain injury
DD - PSYCHIATRIC-Anxiety disorder
EE - PSYCHIATRIC-Depression
FF - PSYCHIATRIC- Bipolar disorder (Manic depression)
GG - PSYCHIATRIC-Schizophrenia
HH - PULMONARY-Asthma
II - PULMONARY-Emphysema/COPD/
JJ - SENSORY-Cataract
KK - SENSORY-Diabetic retinopathy
LL - SENSORY-Glaucoma
MM - SENSORY-Macular degeneration
MM1 - SENSORY- Hearing impairment
NN - OTHER-Allergies
OO - OTHER-Anemia
PP - OTHER-Cancer
QQ - OTHER-Renal failure
RR - None of the Above
SS - OTHER-Other significant illness
2.a. Enter any comments regarding the client's medical
conditions/diagnoses.
3
.
Selec
t all infections that a
pply to the client's
co
ndi
tion
based on the client's c
linical record, consult
staff, physician and accept client statements that seem to
have clinical validity. Do not record infections that have
been resolved.
A
- A
ntibiotic resistant
infection (e.g.
,Met
hicillin resistant
staph)
B - Clostridium difficile (c.diff.)
C - Conjunctivitis
D - HIV infection
E - Pneumonia
F - Respiratory infection
G - Septicemia
H - Sexually transmitted diseases
I - Tuberculosis
J - Urinary tract infection in last 30 days
K - Viral hepatitis
L - Wound infection
M - None
N - Other
4. Indicate what problem conditions the client has had
in the past week.
A - Dehydrated; output exceeds input
B - Delusions
C - Dizziness or lightheadedness
D - Edema
E - Fever
F - Internal bleeding
G - Recurrent lung aspirations in the last 90 days
H - Shortness of breath
I - Syncope (fainting)
J - Unsteady gait
K - Vomiting
L - End Stage Disease (6 or fewer months to live)
M - None of the above
N - Other
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5
. Medi
ca
l treatments that the client rec
eived during
the l
as
t 14
days.
A - TREATMENTS
- Chemotherapy
B - TREATMENTS - Dialysis
C - TREATMENTS - IV medication
D - TREATMENTS - Intake/output
E - TREATMENTS - Monitoring acute medical condition
F - TREATMENTS - Ostomy care
G - TREATMENTS - Oxygen therapy
H - TREATMENTS - Radiation
I - TREATMENTS - Suctioning
J - TREATMENTS - Tracheostomy care
K - TREATMENTS - Transfusions
L - TREATMENTS - Ventilator or respirator
M - None of the Above
N - Other
6. Indicate all therapies received by the client in the
last seven (7) days.
A - Speech therapy
B - Occupational therapy
C - Physical therapy
D - Respiratory therapy
E - None of the above
7. Does the client currently receive at least 45 minutes
per day for at least 3 days per week of PT or a
combination of PT, ST or OT?
A - Yes
B - No
C - Information unavailable
8. Select all that apply for nutritional approaches.
A - Parenteral/IV
B - Feeding tube
C - Mechanically altered diet
D - Syringe (oral feeding)
E - Therapeutic diet
F - Dietary supplement between meals
G - Plate guard, stabilized built-up utensil, etc
H - On a planned weight change program
I - Oral liquid diet
J - None of the above
9. Select all that apply with regards to the client oral
and dental status.
A - Broken, loose, or carious teeth
B - Daily cleaning of teeth/dentures or daily mouth care
—by Client or staff
C - Has dentures or removable bridge
D - Inflamed gums (gingiva);swollen/bleeding gums;oral
abscesses; ulcers or rashes
E - Some/all natural teeth lost, does not have or use
dentures or partial plate
F - None of the above
10. High risk factors characterizing this client?
A - Smoking
B - Obesity
C - Alcohol dependency
D - Drug dependency
E - Unknown
G - None of the above
5B. Health Assessment (for CFC must be completed by
RN/LPN): PAIN STATUS
1. Indicate the client's frequency of pain interfering
with his or her activity or movement.
A - No pain
B - Less than daily
C - Daily, but not constant
D - Constantly
2. If the client experiences pain, does its intensity
disrupt their usual activities? (e.g. sleep, eating, energy
level)
A - Yes
B - No
5C. Health Assessment (for CFC must be completed by
RN/LPN): SKIN STATUS
ULCER KEY. STAGE 1: Persistent area of skin redness(no
break in skin) that doesn't disappear when pressure is
relieved
STAGE2: Partial skin thickness loss, presents as an
abrasion, blister, or shallow crater.
STAGE3: Full skin thickness loss, exposing subcutaneous
tissues, presents as a deep crater.
STAGE 4: Full skin thickness loss, exposing subcutaneous
tissues, exposing muscle or bone.
1
.a. S
pecify the highest ulcer stage
(1-4) for any pressure
ulc
ers the c
lient has (specify 0
if the client has no
pressure ulcers).
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DAIL
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1
.b
. S
pecify the highest ulcer stage
(1-4) for any stasis
ulc
ers
the c
lient has (specify 0
if the client has no
pressure ulcers).
2. Indicate which of the following skin problems the
client has that requires treatment.
A - Abrasions or Bruises
B - Burns (second or third degree)
C - Open lesions other than ulcers, rashes or cuts
D - Rashes
E - Skin desensitized to pain or pressure
F - Skin tears or cuts
G - Surgical wound site
H - None of the above
5D. Health Assessment (for CFC must be completed by
RN/LPN): ELIMINATION STATUS
1. Has this client been treated for a urinary tract
infection in the past 14 days?
A - Yes
B - No
2. What is the current state of the client's bladder
continence (in the last 14 days) Client is continent if
dribble volume is insufficient to soak through underpants
with appliances used (pads or continence program)
A - Yes Incontinent
B - No incontinence nor catheter
C - No incontinence has Urinary catheter
3. What is the frequency of bladder incontinence?
A - Less than once weekly
B - One to three times weekly
C - Four to six times weekly
D - One to three times daily
E - Four or more times daily
4. When does bladder (urinary) incontinence occur?
A - During the day only
B - During the night only
C - During the day and night
5. What is the current state of the client's bowel
continence (in the last 14 days, or since the last
assessment if less than 14 days)? Client is continent if
control of bowel movement with appliance or bowel
continence program.
A - Incontinent
B - No incontinence nor ostomy
C - No incontinence has ostomy
6. What is the frequency of bowel incontinence?
A - Less than once weekly
B - One to three times weekly
C - Four to six times weekly
D - One to three times daily
E - Four or more times daily
7. When does bowel incontinence occur?
A - During the day only
B - During the night only
C - During the day and night
8. Has the client experienced recurring bouts of
diarrhea in the last seven (7) days?
A - Yes
B - No
9. Has the client experienced recurring bouts of
constipation in the last seven (7) days?
A - Yes
B - No
Comments regarding Urinary/Bowel Problems
5E. Health Assessment (for CFC must be completed by
RN/LPN): COMMENTS and RN/LPN SIGNATURE
Comments regarding Medical Conditions
Enter the name of the Agency of RN/LPN.
What is the name of LPN/RN who completed Health
Assessment section. SIGN BELOW
_____________________________________________
6A. Functional Assessment: ACTIVITIES of DAILY LIVING
(ADLs)
KEY TO ADLS :
0=INDEPENDENT: No help at all OR help/oversight for 1-
2 times 1=SUPERVISION: Oversight/cue 3+
times OR oversight/cue + physical help 1 or 2 times.
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2=
LI
MITED ASSIST: Non
-wt bearing physical help
3+ti
mes
OR
non-wt bearing help + ex
tensive help 1-2
times 3=EXTENSIVE ASSIST: Wt-bearing help or full
caregiver assistance 3+ times
4=
TOTAL
DEPENDENCE: Full ca
regiver assistance every
time
8= Activity did not o
ccur OR unknown.
1.A. DRESSING: During the past 7 days, how would you
rate the client's ability to perform DRESSING? (putting
on, fastening, taking off clothing, including prosthesis)
0 - INDEPENDENT: No help or oversight OR help
provided 1 or 2 times
1 - SUPERVISION: Oversight/cueing 3+ times OR
Oversight with physical help 1-2 time
2 - LIMITED ASSISTANCE: Non-wt bearing physical help
3+ times OR extensive help 1-2
3 - EXTENSIVE ASSISTANCE: Weight bearing help OR full
caregiver assistance 3+ times
4 - TOTAL DEPENDENCE: Full assistance every time
8 - Activity did not occur OR unknown
1
.B. S
elect the item for the most suppo
rt provided during
the l
ast 7
days, for Dressing
0
- No
setup or physical h
elp
1 -
Set
up help only
2 - O
ne person physical assist
3 - Two plus persons physical assist
8 - Activity did not occur in last 7 days OR unknown
dressing estimated minutes/day
1.C.1. DRESSING: How many MINUTES per DAY were
needed for assistance in dressing? (Must enter zero if no
time needed)
1.C.2. DRESSING: How many DAYS per WEEK does the
client need PCA for ADL dressing? (Must enter zero if no
time needed)
1.D. Comment on the client's ability in dressing.
2.A. BATHING: During the past 7 days, how would you
rate the client's ability to perform BATHING (include
shower, full tub or sponge bath, exclude washing back or
hair)?
0 - INDEPENDENT: No help at all
1 - SUPERVISION: Oversight/cueing only
2 - LIMITED ASSISTANCE: Physical help limited to
transfer only
3 - EXTENSIVE ASSISTANCE: Physical help in part of
bathing activity
4 - TOTAL DEPENDENCE: Full assistance every time
8 - Activity did not occur OR unknown
2
.B. S
elect the item for the most suppo
rt provided during
the l
ast 7
days, for Bathing.
0
-
No
setup or physical h
elp
1 -
S
et
up help only
2 - O
ne person physical assist
3 - Two plus persons physical assist
8 - Activity did not occur in last 7 days OR unknown
bathing estimated minutes/day
2.C.1. BATHING: How many MINUTES per DAY were
needed for assistance for bathing? (Must enter zero if no
time needed)
2.C.2. BATHING: How many DAYS per WEEK does the
client need PCA for ADL bathing? (Must enter zero if no
time needed)
2.D. Comments regarding the client's bathing.
3.A. PERSONAL HYGIENE During the past 7 days, how
would you rate the client's ability to perform PERSONAL
HYGIENE? (combing hair, brushing teeth, shaving,
washing/drying face, hands, perineum, EXCLUDE baths
and showers)
0 - INDEPENDENT: No help or oversight OR help
provided 1 or 2 times
1 - SUPERVISION: Oversight/cueing 3+ times OR
Oversight with physical help 1-2 time
2 - LIMITED ASSISTANCE: Non-wt bearing physical help
3+ times OR extensive help 1-2
3 - EXTENSIVE ASSISTANCE: Weight bearing help OR full
caregiver assistance 3+ times
4 - TOTAL DEPENDENCE: Full assistance every time
8 - Activity did not occur OR unknown
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3
.B
. S
elect the item for the most suppo
rt provided during
the l
as
t 7
days, for Personal
Hygiene
0
- No
setup or physical h
elp
1 -
Set
up help only
2 - O
ne person physical assist
3 - Two plus persons physical assist
8 - Activity did not occur in last 7 days OR unknown
Personal Hygiene estimated minutes/day
3.C.1. PERSONAL HYGIENE: How many MINUTES per
DAY were needed for assistance for personal hygiene?
3
.
C.2
. PER
S
ONAL
HYGIENE: Ho
w many
DAYS per WEEK
does the client need PCA for ADL personal hygiene?
(Must enter zero if no time needed)
3
.D
. Co
mment on the client's abil
ity to perform personal
hygi
ene
4
.A. MO
BILITY IN BED During
the past 7 days, how would
yo
u rate the
client's ability to
perform MOBILITY IN BED?
(moving to and from lying position, turning side to side,
and positioning while in bed)
0
- IND
EPENDENT: No help o
r oversight OR help
prov
ided 1
or 2 times
1 - S
UPERVISION: Oversight/cueing 3+ times OR
Oversight with physical help 1-2 time
2 - LIMITED ASSISTANCE: Non-wt bearing physical help
3+ times OR extensive help 1-2
3 - EXTENSIVE ASSISTANCE: Weight bearing help OR full
caregiver assistance 3+ times
4 - TOTAL DEPENDENCE: Full assistance every time
8 - Activity did not occur OR unknown
4.B. Select the item for the most support provided during
the last 7 days, for Bed Mobility.
0 - No setup or physical help
1 - Setup help only
2 - One person physical assist
3 - Two Plus persons physical assist
8 - Activity did not occur in last 7 days OR unknown
Mobility in Bed estimated min/day
NOTE: If full assistance is needed more than 6+x/day
Bed Mobility estimated minutes/day =30
4
.C
.1
. BED
MOB
IL
ITY How many
MINUT
ES per DAY
were needed for assistance for bed mobility? (Must enter
zero if no time needed)
4
.C
.2
. BED
MOB
IL
ITY How many
DAYS per WE
EK does
the client need PCA for ADL bed mobility? (Must enter
zero if no time needed)
4.D. Comments on clients bed mobility.
5.A. TOILET USE During the past 7 days, how would you
rate the client's ability to perform TOILET USE? (using
toilet, getting on/off toilet, cleansing self, managing
incontinence)
0 - INDEPENDENT: No help or oversight OR help
provided 1 or 2 times
1 - SUPERVISION: Oversight/cueing 3+ times OR
Oversight with physical help 1-2 time
2 - LIMITED ASSISTANCE: Non-wt bearing physical help
3+ times OR extensive help 1-2
3 - EXTENSIVE ASSISTANCE: Weight bearing help OR full
caregiver assistance 3+ times
4 - TOTAL DEPENDENCE: Full assistance every time
8 - Activity did not occur OR unknown
5.B. Select the item for the most support provided during
the last 7 days, for Toilet Use
0 - No setup or physical help
1 - Setup help only
2 - One person physical assist
3 - Two plus persons physical assist
8 - Activity did not occur in last 7 days OR unknown
toileting estimated minutes/day
NOTE: If full assistance is needed more than 6+x/day
Toileting estimated minutes/day =60
5.C.1. TOILET USE: How many MINUTES per DAY were
needed for assistance for toilet use? (Must enter zero if
no time needed)
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5
.C
.2
. TOI
LE
T
USE: How
many DAYS
per WEEK were
needed for assistance for toilet use? (Must enter zero if
no time needed)
5.D. Comment on the client's ability to use the toilet.
6.A. ADAPTIVE DEVICES: During the past 7 days how do
rate the client's ability to manage putting on and/or
removing braces, splints, and other adaptive devices.
0 - INDEPENDENT: No help or oversight OR help
provided 1 or 2 times
1 - SUPERVISION: Oversight/cueing 3+ times OR
Oversight with physical help 1-2 time
2 - LIMITED ASSISTANCE: Non-wt bearing physical help
3+ times OR extensive help 1-2
3 - EXTENSIVE ASSISTANCE: Weight bearing help OR full
caregiver assistance 3+ times
4 - TOTAL DEPENDENCE: Full assistance every time
8 - Activity did not occur OR unknown
6.B. Specify the most support provided for client's ability
to care for his/her adaptive equipment.
0 - No setup or physical help
1 - Setup only
2 - One person physical assist
3 - Two plus persons physical assist
8 - Activity did not occur in last 7 days OR unknown
Adaptive devices estimated minutes/day
6.C.1. ADAPTIVE DEVICES: How many MINUTES per
DAY were needed for assistance for adaptive devices?
(Must enter zero if no time needed)
6
.C.2
. ADAPTI
VE DE
VICES: How
many DAYS
per WEEK
does the client need PCA for ADL adaptive devices? (Must
enter zero if no time needed)
6
.D. Co
mment on adaptive devices.
7.
A
. TR
ANSFER: During the past 7
days, how would you
rate the client's ability to perform TRANSFER? (moving
to/from bed, chair, wheelchair, standing position,
EXCLUDES to/from bath/toilet)
0 - INDEPENDENT: No help or oversight OR help
provided 1 or 2 times
1 - SUPERVISION: Oversight/cueing 3+ times OR
Oversight with physical help 1-2 time
2 - LIMITED ASSISTANCE: Non-wt bearing physical help
3+ times OR extensive help 1-2
3 - EXTENSIVE ASSISTANCE: Weight bearing help OR full
caregiver assistance 3+ times
4 - TOTAL DEPENDENCE: Full assistance every time
8 - Activity did not occur OR unknown
7.B. Select the item for the most support provided during
the last 7 days, for Transfer.
0 - No setup or physical help
1 - Setup help only
2 - One person physical assist
3 - Two plus persons physical assist
8 - Activity did not occur in last 7 days OR unknown
Transferring estimated minutes/day
NOTE: If full assistance is needed more than 6+x/day
Transferring estimated minutes/day =45 (hoyer)
7.C.1. TRANSFERRING: How many MINUTES per DAY
were needed for assistance for transferring? (Must enter
zero if no time needed)
7.C.2. TRANSFERRING: How many DAYS per WEEK
does the client need PCA for ADL transferring? (Must
enter zero if no time needed)
7.D. Enter any comments regarding the client's ability to
transfer.
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8
.A
. MO
BILITY: During the past
7 days, how would you
rate
the c
li
ent's ability to perform
MOBILITY IN HOME?
(moving between locations in home. If in wheelchair,
self-sufficiency once in wheelchair)
0 - INDEPENDENT: No help or oversight OR help
provided 1 or 2 times
1 - SUPERVISION: Oversight/cueing 3+ times OR
Oversight with physical help 1-2 time
2 - LIMITED ASSISTANCE: Non-wt bearing physical help
3+ times OR extensive help 1-2
3 - EXTENSIVE ASSISTANCE: Weight bearing help OR full
caregiver assistance 3+ times
4 - TOTAL DEPENDENCE: Full assistance every time
8 - Activity did not occur OR unknown
8.B. Select the item for the most support provide for
mobility in last 7 days
0 - No setup or physical help
1 - Setup help only
2 - One person physical assist
3 - Two + person physical assist
8 - Activity did not occur in last 7 days OR unknown
Mobility (walking) estimated min/day
NOTE: If full assistance is needed more than 6+x/day
Mobility estimated minutes/day =45
8.C.1. MOBILITY: How many MINUTES per DAY were
needed for assistance for mobility
(ambulation/locomotion)? (Must enter zero if no time
needed)
8.C.2. MOBILITY: How many DAYS per WEEK does the
client need PCA for ADL mobility? (Must enter zero if no
time needed)
8.D. Comment on the client's ability to get around inside
the home.
9.A. EATING: During the past 7 days, how would you
rate the client's ability to perform EATING? (ability to eat
and drink regardless of skill. Includes intake of
nourishment by other means (e.g. tube feeding, total
parenteral nutrition)
0 - INDEPENDENT: No help or oversight OR help
provided 1 or 2 times
1 - SUPERVISION: Oversight/cueing 3+ times OR
Oversight with physical help 1-2 time
2 - LIMITED ASSISTANCE: Non-wt bearing physical help
3+ times OR extensive help 1-2
3 - EXTENSIVE ASSISTANCE: Weight bearing help OR full
caregiver assistance 3+ times
4 - TOTAL DEPENDENCE: Full assistance every time
8 - Activity did not occur OR unknown
9.B. Select the item for the most support provided during
the last 7 days, for Eating
0 - No setup or physical help
1 - Setup help only
2 - One person physical assist
3 - Two plus persons physical assist
8 - Activity did not occur in last 7 days OR unknown
eating estimated minutes/day
9.C.1. EATING: How many MINUTES per DAY were
needed for assistance for eating? (Must enter zero if no
time needed)
9.C.2. EATING: How many DAYS per WEEK does the
client need PCA for ADL eating? (Must enter zero if no
time needed)
9.D. Comment on the client's ability to eat.
What is the client's ADL count?
10. How many ADL impairments does the client have
(Count or Total)? Must answer for NAPIS.
6B. Functional Assessment: INSTRUMENTAL ACTIVITIES of
DAILY LIVING (IADLs)
1.A. PHONE: During the last 7 days, Rate the client's
ability to use the PHONE. (Answering the phone, dialing
numbers, and effectively using the phone to
communicate)
0 - INDEPENDENT: No help provided (With/without
assistive devices)
1 - DONE WITH HELP: Cueing, supervision, reminders,
and/or physical help provided
2 - DONE BY OTHERS: Full caregiver assistance
8 - Activity did not occur OR unknown
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1
.B
. I
ndicate the highest level of
phone use support
prov
ided
in
the last seven (7) day
s.
0 - No setup or physical help
1 - Supervision/cueing
2 - Setup help only
3 - Physical assistance
8 - Activity did not occur or unknown
1.D. Comment on the client's ability to use the telephone.
2.A. MEAL PREPARATION: During the past 7 days, how
would you rate the client's ability to perform MEAL
PREPARATION? (planning and preparing light meals or
reheating delivered meals)
0 - INDEPENDENT: No help provided (With/without
assistive devices)
1 - DONE WITH HELP: Cueing, supervision, reminders,
and/or physical help provided
2 - DONE BY OTHERS: Full caregiver assistance
8 - Activity did not occur OR unknown
2.B. Indicate the most support provided for meal prep in
the last seven (7) days.
0 - No setup or physical help
1 - Supervision/cueing
2 - Setup help only
3 - Physical assistance
8 - Activity did not occur or unknown
Meal prep estimated minutes/day
2.C.1. MEAL PREP: How many MINUTES per DAY were
needed for assistance for meal preparation? (Must enter
zero if no time needed)
2
.C.2
. MEAL
PREP:
How many DAYS
per WEEK
does the
client need PCA for IADL meal prep? (Must enter zero if
no time needed)
2
.D. Co
mment on the client's abil
ity to prepare meals.
3.
A. MEDI
CATIONS MANAGEMENT:
During the past 7
days, how would you rate the client's ability to perform
MEDICATIONS MANAGEMENT? (preparing/taking all
prescribed and over the counter medications reliably and
safely, including correct dosage at correct times)
0 - INDEPENDENT: No help provided (With/without
assistive devices)
1 - DONE WITH HELP: Cueing, supervision, reminders,
and/or physical help provided
2 - DONE BY OTHERS: Full caregiver assistance
8 - Activity did not occur OR unknown
3.B. Indicate the most support provided for medications
management in the last seven (7) days.
0 - No setup or physical help
1 - Supervision/cueing
2 - Setup help only
3 - Physical assistance
8 - Activity did not occur or unknown
Meds mgt estimated minutes/day
3.C.1. MEDICATIONS MANAGEMENT: How many
MINUTES per DAY were needed for assistance for
medications management. (Must enter zero if no time
needed)
3.C.2. MEDICATIONS MANAGEMENT: How many DAYS
per WEEK does the client need for IADL medications
management? (Must enter zero if no time needed)
3.D. Comment on the client's ability to take his/her
medication.
4.A. MONEY MANAGEMENT: During the last 7 days how
do you rate the client's ability to manage money.
(payment of bills, managing checkbook/accounts, being
aware of potential exploitation, budgets, plans for
emergencies etc.)
0 - INDEPENDENT: No help provided (With/without
assistive devices)
1 - DONE WITH HELP: Cueing, supervision, reminders,
and/or physical help provided
2 - DONE BY OTHERS: Full caregiver assistance
8 - Activity did not occur OR unknown
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4
.B
. I
ndicate the most support provi
ded for money
mana
gement
in
the last seven (7) day
s.
0 - No setup or physical help
1 - Supervision/cueing
2 - Setup help only
3 - Physical assistance
8 - Activity did not occur or unknown
4.D. Comment on the client's ability to manage money.
5.A. HOUSEHOLD MAINTENANCE: During the past 7 days
rate the client's ability to perform HOUSEHOLD
MAINTENANCE. (chores such as washing windows,
shoveling snow, taking out garbage and scrubbing floors)
0 - INDEPENDENT: No help provided (With/without
assistive devices)
1 - DONE WITH HELP: Cueing, supervision, reminders,
and/or physical help provided
2 - DONE BY OTHERS: Full caregiver assistance
8 - Activity did not occur OR unknown
5.B. Indicate the highest level of household maintenance
support provided in the last seven (7) days.
0 - No setup or physical help
1 - Supervision/cueing
2 - Setup help only
3 - Physical assistance
8 - Activity did not occur or unknown
5
.D. Co
mment on the client's abil
ity to perform household
mai
ntenance c
hores.
6
.A. L
IGHT HOUSEKEEPIN
G: During the last 7 days how
wo
uld yo
u rate the client's abil
ity to perform light
housekeeping. (dusting. sweeping, vacuuming, dishes,
light mop, and picking up)
0 - INDEPENDENT: No help provided (With/without
assistive devices)
1 - DONE WITH HELP: Cueing, supervision, reminders,
and/or physical help provided
2 - DONE BY OTHERS: Full caregiver assistance
8 - Activity did not occur OR unknown
6.B. Indicate the most support provided for
housekeeping in the last seven (7) days.
0 - No setup or physical help
1 - Supervision/cueing
2 - Setup help only
3 - Physical assistance
8 - Activity did not occur or unknown
6.D. Comment on the client's ability to do ordinary
housekeeping.
7.A. LAUNDRY During the last 7 days how do rate the
client's ability to perform laundry. (carrying laundry to
and from the washing machine, using washer and dryer,
washing small items by hand)
0 - INDEPENDENT: No help provided (With/without
assistive devices)
1 - DONE WITH HELP: Cueing, supervision, reminders,
and/or physical help provided
2 - DONE BY OTHERS: Full caregiver assistance
8 - Activity did not occur OR unknown
7.B. Indicate the most support provided for laundry in
the last seven (7) days.
0 - No setup or physical help
1 - Supervision/cueing
2 - Setup help only
3 - Physical assistance
8 - Activity did not occur or unknown
7.D. Comment on the client's ability to do laundry.
8.A. SHOPPING: During the past 7 days, how would you
rate the client's ability to perform SHOPPING? (planning,
selecting, and purchasing items in a store and carrying
them home or arranging delivery if available)
0 - INDEPENDENT: No help provided (With/without
assistive devices)
1 - DONE WITH HELP: Cueing, supervision, reminders,
and/or physical help provided
2 - DONE BY OTHERS: Full caregiver assistance
8 - Activity did not occur OR unknown
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8
.B
. I
ndicate the highest level of
shopping support
prov
ided
in
the last seven (7) day
s.
0 - No setup or physical help
1 - Supervision/cueing
2 - Setup help only
3 - Physical assistance
8 - Activity did not occur or unknown
8.D. Comment on the client's ability to do shopping.
9.A. TRANSPORTATION: During the past 7 days, how
would you rate the client's ability to perform
TRANSPORTATION? (safely using car, taxi or public
transportation)
0 - INDEPENDENT: No help provided (With/without
assistive devices)
1 - DONE WITH HELP: Cueing, supervision, reminders,
and/or physical help provided
2 - DONE BY OTHERS: Full caregiver assistance
8 - Activity did not occur OR unknown
9.B. Indicate the highest level of transportation support
provided in the last seven (7) days.
0 - No setup or physical help
1 - Supervision/cueing
2 - Setup help only
3 - Physical assistance
8 - Activity did not occur or unknown
9.D. Comment on the client's ability to use transportation.
10.A. EQUIPMENT MANAGEMENT: During last 7 days
rate client's ability to manage equipment (cleaning ,
adjusting or general care of adaptive/medical equipment
such as wheelchairs, walkers, nebulizer, IV equipment
etc.)
0 - INDEPENDENT: No help provided (With/without
assistive devices)
1 - DONE WITH HELP: Cueing, supervision, reminders,
and/or physical help provided
2 - DONE BY OTHERS: Full caregiver assistance
8 - Activity did not occur OR unknown
10.B. Indicate the highest level of care of equipment
support provided in the last seven (7) days.
0 - No setup or physical help
1 - Supervision/cueing
2 - Setup help only
3 - Physical assistance
8 - Activity did not occur or unknown
11. Is the program application for the client for ASP or
Other programs? If it is not ASP then the following IADL
questions will be skipped.
A - Attendant Services program
B - Other
What is the client's IADL count?
12. How many IADL impairments does the client have
(Count or Total)? Must answer for NAPIS.
6.C.1. ASP Only - Extra IADL Questions
11.A. INFANT/CHILD CARE (ASP only): During last 7
days rate client's ability to perform infant/child care.
(bathing, dressing, feeding of own children to the extent
that dependent child cannot self perform.
0 - - INDEPENDENT: No help provided (With/without
assistive devices)
1 - DONE WITH HELP: Cueing, supervision, reminders,
and/or physical help provided
2 - DONE BY OTHERS: Full caregiver assistance
8 - Activity does not occur
11.B. Indicate the highest level of child care support
provided in the last seven (7) days.
0 - No setup or physical help
1 - Supervision/cueing
2 - Setup help only
3 - Physical assistance
8 - Activity did not occur or unknown
12.A. SUPPORT ANIMAL (ASP only): During last 7
days rate client's ability to care for support animal.
(feeding, grooming, walking seeing-eye dog or
hearing-ear dog or other support animal)
0 - - INDEPENDENT: No help provided (With/without
assistive devices)
1 - DONE WITH HELP: Cueing, supervision, reminders,
and/or physical help provided
2 - DONE BY OTHERS: Full caregiver assistance
8 - Activity does not occur
12.B. Indicate the highest level of support of animals
support provided in the last seven (7) days.
0 - No setup or physical help
1 - Supervision/cueing
2 - Setup help only
3 - Physical assistance
8 - Activity did not occur or unknown
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13
.A
. MO
B
IL
IT
Y GUIDE (ASP only): For individuals
who are blind or visually impaired, during last 7 days rate
client's level of mobility. (get from place to place in and
around home, shopping, and in medical or educational
facilities)
0 - - INDEPENDENT: No help provided (With/without
assistive devices)
1 - DONE WITH HELP: Cueing, supervision, reminders,
and/or physical help provided
2 - DONE BY OTHERS: Full caregiver assistance
8 - Activity did not occur or unknown
13.B. Indicate the highest level of mobility guide
support provided in the last seven (7) days.
0 - No setup or physical help
1 - Setup help only
2 - Supervision/cueing
3 - Physical assistance
8 - Activity did not occur or unknown
6.C.2. ASP only worksheet questions
1.C.1. PHONE: (only enter for ASP) How many
MINUTES per DAY were needed for assistance for phone
use. (must enter zero if no time is needed)
1.C.2. PHONE: (enter for ASP only) How many DAYS
per WEEK does the client need PCA for IADL phone use?
(enter zero if no time needed)
4
.C.1
. MON
EY MANAGE
MENT: (only
enter for AS
P) How
many MINUTES per WEEK were needed for assistance for
MONEY MANAGEMENT. (must enter zero if no time is
needed)
5
.C.1
. HOU
SEHO
LD MAINTENAN
CE: (onl
y enter for
ASP) How many MINUTES per WEEK were needed for
assistance for HOUSEHOLD MAINTENANCE. (must enter
zero if no time is needed)
6.C.1. LIGHT HOUSEKEEPING: (only enter for ASP)
How many MINUTES per WEEK were needed for
assistance for LIGHT HOUSEKEEPING. (must enter zero
if no time is needed)
8.C.1. SHOPPING: (only enter for ASP) How many
MINUTES per WEEK were needed for assistance for
SHOPPING. (must enter zero if no time is needed)
9
.C
.1
. TRAN
SPO
RT
ATION: (EN
TER FO
R asp ONLY) How
many MINUTES per WEEK were needed for assistance for
transportation? (Must enter zero if no time needed)
10
.C
.1
. EQU
IPME
NT
MANAGEMENT: (
only enter
for ASP)
How many MINUTES per WEEK were needed for
assistance for EQUIPMENT MANAGEMENT. (must enter
zero if no time is needed)
11.C. CHILD CARE: How many MINUTES per WEEK
were needed for assistance for child care?
12.C.1. SUPPORT ANIMAL CARE: How many MINUTES
per WEEK were needed for assistance for care for
support animal?
13.C.1. MOBILITY GUIDE: How many MINUTES per
WEEK were needed for assistance for mobility guide?
14
. ADAPTI
VE EQUIPMENT : (only enter for ASP) How
many MINUTES per WEEK were needed for assistance for
ADAPTIVE EQUIPMENT (must enter zero if no time is
needed)
E
nter any
comments regarding the client's
ability to
perform
Mobil
ity Outdoors.
6D. Functional
Assessment: ADL/IADL Unmet Needs
Enter any additional comments regarding IADLs.
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Vermont DAIL Independent Living Assessment
ADL
/I
ADL
Comments- Identify unmet needs if any
.
Vari
anc
e reques
t must include
1. Descriptio
n of client's specific unmet need
2. Why unmet need cannot be met with other services
3. Actual/immediate risk client's to health/welfare posed
by unmet need
7A.
Esti
mated/requested Incontinence needs:
Bow
el
needs
estimated min/day
BOWEL:
How many MINUTES per DAY were needed for
assistance for bowel incontinence?
BOWEL: How many DAYS per WEEK were needed for
assistance for bowel incontinence?
Urinary needs estimated min/day
BLADDER: How many MINUTES per DAY were needed for
assistance for bladder incontinence?
BLADDER: How many DAYS per WEEK were needed for
assistance for bladder incontinence?
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Vermont DAIL Independent Living Assessment
2.
Ca
lc
ulated needs for HCBS Persona
l Care Worksheet
2.A.
Ca
lc
ulated ADL/Meal Prep + Meds Mana
gement needs
Dressing minutes/week
bathing minutes/week calculated
Hygiene min/week calculated
Bed mobility min/week calculated
Toilet min/week calculated
Adap device min/week calculated
Transfer min/week calculated
Mobility min/week calculated
Eating min/week calculated
Total ADL min/week calculated
Total ADL hours/week calculated
Meal prep min/week calculated
Med mgt min/week calculated
2.B. Calculated Incontinence needs
urinary needs min/week calculated
Bowel needs min/week calculated
2.C. LTC Waiver (Choices for Care) Calculated Needs
Total Incontinence hrs/week calculated
Total ADL + meal prep +meds mgt min/wk
hours per day for IADL tasks?
days per week assistance needed with IADL tasks?
Enter min/week for all IADLs except Meal Prep and
Medication Management. Cannot exceed 270 (max IADL
min/wk allowed).
Enter Comments on min/week for all IADLs except Meal
Prep and Medication Management. Cannot exceed 270
(max IADL min/wk allowed).
Total IADL assistance min/week
Max IADL min/wk allowed
Total IADL max min/wk
Total LTC Waiver min/wk
Total LTC Waiver hrs/wk
Total LTC Waiver hrs/2 wks
Total LTC Waiver hrs/mo
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Vermont DAIL Independent Living Assessment
click to sign
signature
click to edit
click to sign
signature
click to edit
3.
Po
tentia
l Issues Checklist
3.A.
H
eal
th Issues checklist (
1 indicates area for follow-up)
Issue Emergency preparedness
Issue Client lives alone
Issue Client has Fallen recently
Issue Nutritional Risk (>=6)
Issue Prescription meds (>=5)
Issue depressed,anxious,hopeless
Issue Incontinent bowels or urinary
Issue Pain disrupts usual activities
Issue End Stage Disease -6 or fewer months to live
3.B. Other Issues checklist (1 indicates area for follow-up)
Issue No Power of Attorney
Issue No Advance Directives
Issue Lost/gained 10 pounds
Issue No money to buy food
Issue Client in poverty
Issue No Medigap insurance
Issue Client refuses services
Issue Client has dangerous behavior
Issue Client cannot make clear decisions
Issue Evidence of abuse
Issue Thought about harming self
Issue Plan for harming self
Issue Means to carry out plan to harm self
Issue Getting lost/wandering
Issue Wandering behavior not alterable
Issue Verbally abusive behavior not alterable
Issue Physical abuse behavior not alterable
Issue Sanitation hazards
Issue Structural barriers in home
Issue Living space hazards
Issue Wants other program-service
Issue Needs equipment repaired
3.C. Acuity Scores
Acuity ADLs (max 32)
Acuity IADLs (max 18)
Acuity cognition (max 15)
Acuity bladder continence
Acuity bowel continence
Acuity total score (max 73)
ACUITY percent
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D
ate
Ti
t
le :
D
ate
Title :
VT DA
IL Fu
ll ILA11
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Vermont DAIL Independent Living Assessment
Caregiv
er Evaluation
Car
egive
r’s N
ame:
In
itial E
valu
ation Date:
Re-e
valuat
ion Dat
e:
Ite
ms
:
No
Ye
s
T
ime
De
pendency Items: Do you Feel ~
0 1
He
/she nee
ds my
help to perform many daily
task
He
/she is depend
ent on
you
You ha
ve to wa
tc
h him/her constantly
You ha
ve to help him
/her
with m
an
y ba
sic functions
You don’
t have
a mi
nute’s break from his/her chores
De
velop
me
nt Items: Do you Feel ~
Tha
t y
ou wa
nt to escape from this situation
Your
social l
ife ha
s suffered
Emot
ionally
dra
ined due to caring for him/her
Thing
s
would be
diffe
re
nt at this point in your life
C
omple
tely
overwhelmed/lonely
A loss of pr
ivacy
and/o
r personal time
You don’
t have
enou
g
h k
nowle
dge
or e
x
pe
rie
n
c
e
t
o g
ive
care as well as you would like
P
hysical H
ealth I
tems: Do you Feel ~
Tire
d
– not getti
ng
enou
gh sleep
Your
hea
lth ha
s suffered
(he
ada
che
s, stomach problems, etc.)
You ha
ve trouble
ke
eping your mind on what you were doing
You ha
ve diff
ic
ulty making decisions
You ha
ve ha
d c
rying spells
or
dee
p sadn
ess
You ha
ve
f
reque
nt pa
in
(
bac
k pain, et
c.)
Ha
ve
you los
t or gained 10 pounds in the past 6 months
S
ocial
Relation
ships Items: Do you Feel ~
You don’
t get alon
g with ot
her family members as well as y
ou used to
M
y c
are
giving efforts aren’t appreciate
d by
other
s in m
y f
amily
You’
ve ha
d proble
ms with your marriage (or other signific
ant relationship)
You don’
t get alon
g
a
s
w
ell
as
you used to with others
E
mot
ional H
ealth Items: Do you Feel ~
Emba
rra
ssed ove
r his/her behavior
Unc
omfortable
whe
n
y
ou ha
ve f
riends over
(soc
ial r
elations
hips)
R
ese
ntme
nt towards him/her
Upse
t tha
t the
person I’m caring for has cha
nged so much from his/her former self
F
ami
ly
members
ar
en
’t
he
lping
y
ou with Caregiving responsibilities?
S
trained be
twee
n work
a
nd fami
ly
responsibilities
20-30 P
lus Ca
reg
iver needs relief
/ 10-19 C
areg
iv
er needs assistance
/ 0-9 C
ar
egi
ver needs to be contacted
an
nuall
y.
T
otal S
cor
e
Ac
ce
ss Ca
re Coordinator’s Signature Date
Caregiver’s Signature Date
I
give
pe
rmission for sharing of in
formation directly related to my health, social, environmental and economic status with those
agencies potentially providing services as necessary for up to one year to assist me in receiving the most appropriate care in the
most appropriate environment. I further understand that data gathered as result of these services provided for me may be used in
reporting and research. These results will be released to the Wyoming Department of Health, Aging Division for statistical study and
service verification and my confidentiality will be maintained.
O
ctober
2012
139
Wyoming Caregiver Evaluation
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