Fillable The Functional Assessment Form (Armed Forces Retirement Home)

Fill Online, Printable, Fillable, Blank The Functional Assessment Form (Armed Forces Retirement Home) Form

Use Fill to complete blank online ARMED FORCES RETIREMENT HOME (DC) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

The Functional Assessment Form (Armed Forces Retirement Home)

On average this form takes 43 minutes to complete

The The Functional Assessment Form (Armed Forces Retirement Home) form is 6 pages long and contains:

0 signatures
44 check-boxes
151 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Armed Forces Retirement Home

BROWSE ARMED FORCES RETIREMENT HOME (DC) FORMS

Related forms

The Medical Examination Form (Armed Forces Retirement Home)
PROOF OF ELIGIBILITY: Submit proof of military eligibility, (Armed Forces Retirement Home)
The Personal Profile And Survey / Communications (Armed Forces Retirement Home)
The Mental Health Evaluation Form (Armed Forces Retirement Home)
APP your military documentation and health insurance information (Armed Forces Retirement Home)
Application And Entry Survey (Armed Forces Retirement Home)
AFRH PRE-ADMISSIONS CHECKLIST (Armed Forces Retirement Home)
APP 1. Submit all of the required forms (Armed Forces Retirement Home)
Eye Clinic / Wellness Center 228-897-4467 Optometrist Thurs (Armed Forces Retirement Home)
Armed Forces Retirement Home (Armed Forces Retirement Home)
Armed Forces Retirement Home (Armed Forces Retirement Home)

Fill has a huge library of thousands of forms all set up to be filled in easily and signed.

Fill in your chosen form

Sign the form using our drawing tool

Send to someone else to fill in and sign.

find another form

Redo

Arial Font

Arial
Calibri
Roboto
Open Sans

AFont color

AB
A.B
A..B
A...B
A....B

Remove Field

ADD FIELDS

Cover Page FA 01-2021

Prior Versions No Longer Valid

FUNCTIONAL

ASSESSMENT

Dear Applicant:

All prospective residents must be able to live

independently upon acceptance into the retirement

home. The Functional Assessment evaluates the

candidate’s Activities of Daily Living (ADL’s). The

attached assessment must be completed by a

LICENSED OCCUPATIONAL THERAPIST (OT) or a

PHYSICAL THERAPIST (PT) not a physician, nurse,

corpsman or other health care professional. If you have

questions regarding this assessment, please contact

the Public Affairs Office.

Thank you

AFRH

RETURN ASSESSMENT TO:

ARMED FORCES RETIREMENT HOME

PUBLIC AFFAIRS OFFICE #584

3700 NORTH CAPITOL ST, NW

Washington, DC 20011-8400

Fax Number: (202) 541-7519

Telephone: (800) 422-9988 opt. 1

If FAXING documents to AFRH, please make a black

& white copy before sending the fax so that it will

be legible when it arrives. Please call and let us

know to look for the documents to come through

as well – Thank you for your help! We want to

prevent any delays in processing applications.

Take this form to

OT / PT Therapist

Cover Page FA 01-2021

Prior Versions No Longer Valid

PRIVACY ACT STATEMENT

AUTHORITY: 10 U.S.C 136, Under Secretary of Personnel and Readiness; 24 U.S.C. 401, Armed Forces Retirement

Home; DoD Directive 5124.09 Assistant Secretary of Defense for Personnel and Readiness Force Management;

DoD Instruction 1000.28, Armed Forces Retirement Home (AFRH); and E.O. 9397 (SSN), as amended.

PURPOSE: To determine and verify eligibility for admission to the AFRH.

ROUTINE USE(S): In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act

of 1974, as amended, the records contained herein may specifically be disclosed outside the DoD as a routine

use pursuant to 5 U.S.C. 552a(b)(3) as follows: To the Federal Reserve for processing the debt on the resident

account; To authorized contractors or vendors for the purpose of providing medical services to the residents of

the Armed Forces Retirement Home; To any Federal agency which provides medical services to residents of the

Armed Forces Retirement home; To the Inspector General of the Department of Defense or his/her designee,

for conducting inspections of AFRH records; To a Federal agency, or an organization or person contracting with

the AFRH for information needed in the performance of official duties related to reconciling or reconstructing

data files, compiling descriptive statistics, and/or making analytical or financial studies to support the function

for which the records were collected and maintained; Law Enforcement Routine Use; Congressional Inquiries

Disclosure Routine Use; Disclosure of Information to the National Archives and Records Administration Routine

Use; Disclosure to the Merit Systems Protection Board Routine Use; and Data Breach Remediation Purposes

Routine Use.

The applicable system of records notice is DPR 38 DoD, Armed Forces Retirement Home electronic Resident

Information System (eRIS) and is available at: (ADD LINK WHEN PUBLISHED).

DISCLOSURE: Voluntary; however, failure to provide the required information may result in the delay or denial

of admission.

ARMED FORCES RETIREMENT HOME

Functional Assessment

Form Completed by a Licensed Occupational or Physical Therapist

___________________

____

_________

Last Name

First Name

Birthdate

___________________

____

_________

Street Address

City

State

Zip Code

Page 1 of 4 FA 01-2021

OT/PT please initial EACH page: Prior Versions No Longer Valid

This assessment is required for all applicants seeking admission to the Armed Forces Retirement Home and must be completed and

signed ONLY by a licensed occupational or physical therapist: NOT by a doctor, nurse, or other healthcare practitioner, or the

resident candidate. Please answer the following questions based on your professional judgment, observation and functional tests

administered during the applicant’s visit and initial each page of the assessment. Answers are subject for verification for accuracy

purposes and all “Yes” answers need to be explained. “Yes” answers may or may not affect you application approval.

The following responses are to be completed by a LICENSED PHYSICAL THERAPIST or OCCUPATIONAL THERAPIST only. Provider please

give a full explanation of ANY positive response to the following:

1. Requires and/or receives assistance using the telephone? (Such as: dialing, receiving, calling 911)

_____________________________________________________________________________________________

Ⓨ

Ⓝ

2. Requires and/or receives assistance with transportation? (such as: planning, driving, bus, plane, taxi usage)

_____________________________________________________________________________________________

Ⓨ

Ⓝ

3. Requires and/or receives assistance on incline, decline, or curbs?

_____________________________________________________________________________________________

Ⓨ

Ⓝ

4. Requires and/or receives assistance shopping? (Such as: clothes, hygiene, grooming products)

_____________________________________________________________________________________________

Ⓨ

Ⓝ

5. Requires and/or receives assistance to recall current events, locations, dates, or names?

_____________________________________________________________________________________________

Ⓨ

Ⓝ

ARMED FORCES RETIREMENT HOME

Functional Assessment

Form Completed by a Licensed Occupational or Physical Therapist

___________________

____

_________

Last Name

First Name

Birthdate

___________________

____

_________

Street Address

City

State

Zip Code

Page 2 of 4 FA 01-2021

OT/PT please initial EACH page: Prior Versions No Longer Valid

Ⓨ

Ⓝ

6. Requires and/or receives assistance with meals? (i.e. feeding, carrying tray, diet management)

_____________________________________________________________________________________________

Ⓨ

Ⓝ

7. Requires and/or receives assistance with maintaining/cleaning living quarters and personal laundry?

(Such as: sweeping/vacuuming, making bed, cleaning bathroom, washing garments)

_____________________________________________________________________________________________

Ⓨ

Ⓝ

8. Requires and/or receives assistance with personal hygiene? (Such as: bathing, grooming, dressing)

Please indicate specific needs such as a grab bar, bath stool, supervision, or otherwise.

_____________________________________________________________________________________________

Ⓨ

Ⓝ

9. Requires and/or receives therapy services? (to address weight, pain, cognition, ADL, wound care)

_____________________________________________________________________________________________

Ⓨ

Ⓝ

10. Requires and/or receives assistance of a mobility device? (Such as: wheelchair, person, cane, walker, etc.)

_____________________________________________________________________________________________

ARMED FORCES RETIREMENT HOME

Functional Assessment

Form Completed by a Licensed Occupational or Physical Therapist

___________________

____

_________

Last Name

First Name

Birthdate

___________________

____

_________

Street Address

City

State

Zip Code

Page 3 of 4 FA 01-2021

OT/PT please initial EACH page: Prior Versions No Longer Valid

11. Requires and/or receives assistance with toileting? (i.e. transfer, removing/reapplying clothes) If so, describe

any specific requirements or equipment necessary (colostomy, ileostomy, catheter, raised toilet seat, grab bar,

bed pan, incontinent supplies, etc.)

_____________________________________________________________________________________________

Ⓨ

Ⓝ

12. Requires and/or receives assistance with transfers? (From chair, bed, bath, vehicle, etc.)

_____________________________________________________________________________________________

Ⓨ

Ⓝ

13. Requires and/or receives assistance for daily decision making? (Such as: cues, supervision) If so, describe

cognitive abilities and limitations.

_____________________________________________________________________________________________

Ⓨ

Ⓝ

14. Does the individual have difficulty walking distances over 50 feet (with or without resting periods)?

Please indicated the Furthest Distance walked during this session: (Select One)

Ⓨ

Ⓝ

Over 150 Feet

26-50 Feet

Less than 10 Feet

51-149 Feet

10-25 Feet

Unable to Walk

15. Was there any walking support used during this demonstration: (If so, select all that apply)

Ⓨ

Ⓝ

Cane / Walker / Crutches

Parallel Bars

Oxygen / Breathing Equipment

Prosthesis

Service Dog (physical/medical)

1-2 persons assisting

Leaning on something in area

Other: ____________________________________________________

16. Requires and/or uses mobility devices on a regular basis: (select all that apply)

Ⓨ

Ⓝ

Wheelchair (manual)

Raised Toilet Seat

Escort

Powered Wheelchair / Scooter

Shower chair / Bathing Stool

Grab Bars

Cane / Walker / Crutches

Powered Recliner / Lifting Chair

Other: ____________________

ARMED FORCES RETIREMENT HOME

Functional Assessment

Form Completed by a Licensed Occupational or Physical Therapist

___________________

____

_________

Last Name

First Name

Birthdate

___________________

____

_________

Street Address

City

State

Zip Code

Page 4 of 4 FA 01-2021

OT/PT please initial EACH page: Prior Versions No Longer Valid

Ⓨ

Ⓝ

17. Requires assistance and/or experiences falls when transferring from mobility device to toilet, bed, bath, etc.?

_____________________________________________________________________________________________

Ⓨ

Ⓝ

18. Requires and/or currently lives in a situation where some assistance is provided (within past 6 months)? Select

the living situation/s which best describes the individual’s recent accommodations:

Independent Living Situations:

Living Situations with some assistance given:

Homeowner (House, Condo, etc.)

At Home, with some aid from Family or Caretaker

Renting or Leasing (Apartment, etc.)

Receiving Home Health Care in Home/Apartment

Independent Senior (over 50) Living Community

Assisted Living Facility

Independent – Traveling, RV, or Nomadic Lifestyle

Nursing Home

Other: ___________________________________

Ⓨ

Ⓝ

19. Does this person currently with a family member or somebody else? If so, with whom (response is optional)?

Lives Alone Lives with Family or Spouse Lives with a roommate or friend

Name: __________________________________________________________________________________

Relationship: __________________________________________________________________________________

Ⓨ

Ⓝ

20. Who participated in this assessment?

Applicant

Family Member

Significant Other / Spouse

Caretaker

Friend

Other: _____________________

Your signature below indicates that you have assessed this individual and the answers to the questions are

accurate based on your professional judgement as a LICENSED OCCUPATIONAL OR PHYSICAL THERAPIST

Printed Contact information* (Stamp is acceptable)

Signature and License Number Required

Therapist Name:

Title:

Street Address

Signature

Date

City, ST ZIP

Occupational Therapist

Physical Therapist

Phone Number

Fax Number*

*REQUIRED INFORMATION

License Number

State

END

Sign the document

DRAW TYPE UPLOAD

Choose file

Sending Options

Clear

Adding Fields

Fields are being added to your document to make it really easy to fill, send and sign this PDF. Once finished you can manually add any additional fields and signatures to the document by dragging them from the toolbar.

For larger documents this process may take up to one minute to complete

Finish

Download
Save PDF to desktop

Email
Email completed PDF

Send for Signing
Email for others to sign

Print
Print document

Send for signing

Email for others to sign

Choose a Field
Click on a field and
select the person that should complete it

Want to add a signature?
You can add a signature field
and assign it to someone else
to sign

Send for signing

Email for others to sign

Choose a Field
Click on a field and
select the person that should complete it

Send for signing

Email for others to sign

Someone else

NAME

Email completed PDF

Template

Convert to a reusable Template

Complete document

The Functional Assessment Form (Armed Forces Retirement Home)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 21 June 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document

You're on your way to completing your first doc!

already registered?

First 20 documents completely FREE!

No credit card required

Digitally sign with 1 click

Request signatures from others

Secure storage for sensitive data

Upload your own forms

Simple PDF editing

Huge library of 1000's of forms