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
DCOA CG Assessment Form 7-14-10

1

 

DC OFFICE ON AGING 

CAREGIVER ASSESSMENT- 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 you consider your caregiving responsibilities to be? 

[ ] 24 hours [ ] full time [ ] part time [ ] occasional 

ADL and IADL needs that you or others provide to the care receiver: 

Task No 

help

Super

-vise

Assist Total

Care

Task No 

help

SuperviseAssist Total 

Care

Bathing Shopping

Grooming Cleaning

Eating Transportation

Toileting Yard Work

Mobility Bill Paying

Walking Heavy

Cleaning

TransferringMedications

Management

Dressing Use of

Telephone

Therapy/

Exercise

Escort

Meals Medical 

Appts

Laundry Coordinate 

Services

District of Columbia Caregiver Assessment – Reassessment 4
DCOA CG Assessment Form 7-14-10

2

Do you also provide care for someone 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 [ ] not able to work due to care for CR 

Informal Support

How would 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 

[ ] poor, no willing family members 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: 

_________________________________________________________________________ 

_________________________________________________________________________

_________________________________________________________________________

Living Arrangements

Caregiver’s living arrangement/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 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

Health/Mental Health

Would you describe your health as: 

[ ] excellent [ ] good [ ] fair [ ] poor 

District of Columbia Caregiver Assessment – Reassessment 5
DCOA CG Assessment Form 7-14-10

3

Do you have any medical conditions or physical limitations? [ ] Yes [ ] No (LIST ALL) 

 

How do you describe your emotional health? 

[ ] excellent [ ] good [ ] fair [ ] poor 

Recently, have you experienced 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? 

________________________________________________________________________ 

_________________________________________________________________________ 

Stress

Are you 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 

[ ] personal health concerns [ ] legal arrangements regarding care receiver (power of 

 [ ] family attorney, advice directives, wills) 

 [ ] other: _________________________________________________________________ 

Coping

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? 

District of Columbia Caregiver Assessment – Reassessment 6
DCOA CG Assessment Form 7-14-10

4

One important lesson you have learned and can recommend to other caregivers? 

 

Resource Utilization

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 

[ ] Written 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 

 

CARE RECEIVER INFORMATION

The following questions are about your older relative/friend: 

Care Receiver Name: __________________, __________________, ______________ 

 (last) (first) (mi.) 

Address: __________________________________, Zip Code __________________ 

 

Ward______________ Phone: ___________________ Date of Birth _______________ 

Care Receiver’s Gross monthly income: $_____________ Source: ________________ 

Insurance:____________________________________________________________ 

Health/Mental Health Inventory

Description of care receiver’s current health status, illnesses and disabilities: 

Alert:[ ]Yes [ ]No Oriented to: [ ]Person [ ]Place [ ]Time Ambulatory: [ ]Yes [ ]No 

Incontinence: [ ]Bowel [ ]Bladder 

Can be left alone Yes No Comment:________________________________________ 

Description of care receiver’s emotional health: 

What health issue causes you the greatest concern and why? 

District of Columbia Caregiver Assessment – Reassessment 7
DCOA CG Assessment Form 7-14-10

5

Resource Utilization

What community resources does 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: 

__________________________________________________________________________ 

__________________________________________________________________________ 

District of Columbia Caregiver Assessment – Reassessment 8
DCOA CG Assessment Form 7-14-10

6

Caregiver Support Plan 

Caregiver 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 understand the elements of this support plan and am willing to implement the plan. 

____________________________________ ________________________________________

Caregiver Signature and Date Assessor Signature and Date

District of Columbia Caregiver Assessment – Reassessment 9
DCOA CG Assessment Form 7-14-10

7

Post visit comments 

Rate the potential 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 you think the Care Receiver will use the services recommended today? 

[ ] Yes [ ] No 

[ ] Yes, under the following conditions____________________________ 

__________________________________________________________ 

Do you think the Care Giver will follow through with services recommended today? 

[ ] Yes [ ] No 

[ ] Yes, under the following conditions____________________________ 

_________________________________________________________ 

District of Columbia Caregiver Assessment – Reassessment 10
1

CASE MANAGER: ASSESSMENT DATE: 

D.C. OFFICE ON AGING

CAREGIVER ASSESSMENT

CAREGIVER PROFILE  New Client  Reassessment

Social Security #.________________ Date of Birth__________________ __

Referral Source_______________________ _ 

Caregiver Name: ______________________, ____________________, ____________ 

(last) (first) (mi.) 

Address: _______________________________________________ Zip Code__ __ 

 

Phone: Day ______________Evening_____________ Caregiver for how long?_____ _ 

Emergency Contact for Caregiver: __________________________________________ 

Your Relationship to Care Receiver: 

 spouse  child  step child  friend/neighbor  sibling  other ___ ____ 

Do you consider your caregiving responsibilities to be? 

 24 hours  full-time  part-time  occasional 

ADL/IADL assistance that you or others provide to the care receiver: 

Task No 

Help

Super

-vise

Assist Total

Care

Task No 

Help

Super

-vise

Assist Total

Care

Bathing Shopping

Grooming Cleaning

Eating Transporting

Toileting Yard Work

Mobility Bill Paying

Walking Heavy

Cleaning

TransferringMedication

Mgmt

Dressing Use of

Telephone

Therapy/

Exercise

Escort

Meals Medical 

Apptmts

Laundry Coordinate Serv

Do you also provide care for someone else?  Yes  No

District of Columbia Caregiver Assessment for SSN Case Managers 11
2

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  not able to work due to care for CR 

Informal Support

How would 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 

 poor, no willing family members 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: 

_______________________________________________________________ 

_______________________________________________________________ 

Living Arrangements

Caregiver’s living arrangement/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? 

District of Columbia Caregiver Assessment for SSN Case Managers 12
3

Name Age Gender Relationship 

___________________________________________________________________ 

___________________________________________________________________ 

___________________________________________________________________ 

Health/Mental Health

Would you describe your health as: 

 excellent  good  fair  poor

Do you have any medical conditions or physical limitations?  Yes (LIST ALL)  No

 

________________________________ ________________________________ 

________________________________ ________________________________ 

________________________________ ________________________________ 

How do you describe your emotional health? 

 excellent  good  fair  poor

Recently, have you experienced 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? 

______________________________________________________________________ 

______________________________________________________________________ 

Stress

Are you 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) 

District of Columbia Caregiver Assessment for SSN Case Managers 13
4

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 such as: (READ LIST, Mark ALL 

that apply) 

 children  legal arrangements regarding care receiver 

 marriage (i.e., power of attorney, advance directives, 

 family wills)

 personal health concerns  other ____ _ 

 work 

Coping

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? ______________________________ 

______________________________________________________________________ 

______________________________________________________________________ 

One important lesson you have learned and can recommend to other Caregivers? 

______________________________________________________________________ 

Resource Utilization

Have you used community resources to help YOU?  Yes  No (Skip next Q.) 

District of Columbia Caregiver Assessment for SSN Case Managers 14
5

What are the community resources you currently use? 

 Caregiver support group 

 Name of Support Group Sponsor______________________________________ 

 Caregiver educational program 

 Respite care (i.e., day care, home care) 

Service/Provider___________________________________________________ 

 Caregiver Institute 

 Written resource materials 

 Other________________________________ 

Why haven’t you used community resources for caregivers? 

 Did not know about them

 Do not have the time 

 Financial barriers 

 Transportation barriers

 Other________________________________ 

CARE RECEIVER INFORMATION

The following questions are about your older relative/friend: 

Care Receiver Name: __________________, __________________, ______________

 (last) (first) (mi.) 

Address: __________________________________, Zip Code ___________ _______ 

 

Ward______________ Phone: ___________________ Date of Birth______ _____ 

Care Receiver’s Gross monthly income: $_______________ Source______________ 

Insurance _____________________________________________________________ 

Health/Mental Health Inventory

Description of care receiver’s current health status, illnesses and disabilities: 

ALERT Yes ORIENTED  Person AMBULATORY  Yes 

  No  Place  No

  Time 

CAN BE LEFT ALONE  Yes INCONTINENCE  Bladder 

  No  Bowel 

Comments: 

District of Columbia Caregiver Assessment for SSN Case Managers 15
6

Description of care receiver’s emotional health: 

______________________________________________________________________ 

What health issues cause you the greatest concern and why? 

______________________________________________________________________ 

______________________________________________________________________ 

Resource Utilization

What community resources does the older person use and how often? 

Service Provider Frequency 

___________________________________________________________________ 

___________________________________________________________________ 

___________________________________________________________________ 

Does the older person resist using services?  Yes  No

If yes, why? ___________________________________________________________ 

______________________________________________________________________ 

______________________________________________________________________ 

Are there services, supplies or equipment you need for yourself or the older person that 

you cannot afford at this time?  Yes  No If yes, list below: 

District of Columbia Caregiver Assessment for SSN Case Managers 16
7

______________________________________________________________________ 

Other Comments/issues of concern/recommendations not addressed elsewhere in this 

assessment: 

______________________________________________________________________ 

CAREGIVER SUPPORT PLAN

A. Self Care and Stress Management Recommendations (Mark ALL that apply) 

 1 Attend caregiving support group 

District of Columbia Caregiver Assessment for SSN Case Managers 17
8

 2 Attend educational seminars 

 3 Use respite care 

 4 Get physical exam 

 5 Start a fitness program 

 6 Participate in a hobby

 7 Attend counseling 

 8 Learn and practice stress reduction techniques 

 9 Let others help you 

B. 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, day care programs, etc.) and 

identifying family members and friends who can provide informal support and the type 

of support needed. 

Services 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.) 

______________________________________________________________________ 

______________________________________________________________________ 

______________________________________________________________________ 

______________________________________________________________________ 

______________________________________________________________________ 

District of Columbia Caregiver Assessment for SSN Case Managers 18
9

POST VISIT COMMENTS 

Rate the potential for the 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 Higher potential for situation to collapse 

Do you think the Care Receiver will follow through with services recommended today? 

 Yes 

 Yes, under the following conditions ______________________________________ 

_____________________________________________________________________ 

 

 No

Do you think the Caregiver will follow through with services recommended today? 

 Yes 

 Yes, under the following conditions ______________________________________ 

_____________________________________________________________________ 

 

 No

OoA Caregiver Assessment Form 12-15-04

District of Columbia Caregiver Assessment for SSN Case Managers 19
KANSAS DEPARTMENT FOR AGING AND DISABILITY SERVICES

III-E CAREGIVER ASSESSMENT PLAN KAMIS ID #

KDOA Form SS-025 Revised 07/01/2012(KDADS)

I. INTAKE Initial

Interviewer PSA Date of Assessment Reassessment

II. CAREGIVER CATEGORY

Caregiver (Complete Sec. III, V, VI, and VII)

Grandparent: 

Caring for child(ren) < 19 years of age (Complete Sec. III, IV, and VII)

Caring for disabled adult(s) 19-59 years of age (Complete Sec. III, IV, VI, and VII)

III. CAREGIVER INFORMATION Male

Female

Name (First, Middle, Last) DOB SSN

Ethnicity: Not Hispanic or Latino Hispanic or Latino

Race: African American Hispanic Reporting other race

 American Indian/Alaska Native Native Hawaiian/Pacific Islander White/Non-Hispanic

 Asian Reporting 2 or more races

Address City County State Zip Code

 Urban

 Rural Home Phone Work Phone Cell Phone

IV. CAREGIVER for Child(ren) or Disabled Adult(s):

Number of children cared for: Number of disabled adults cared for: 

Relationship to Child(ren)/Disabled Adult(s) Grandparent Elderly Relative Elderly Non-relative

V. CAREGIVER for Adult - Relationship to Recipient Husband Wife

Daughter/Daughter-in-law Son/Son-in-law Other Relative Non-relative

VI. ADULT CARE RECIPIENT #1 INFORMATION:

Qualifying Care Recipient: Senior 60 years or older Adult w/Alzheimer’s <60 Disabled Adult 19-59

 Male

Female

Name (First, Middle, Last) DOB Recipient SSN

Address City County State Zip Code

 Urban

 Rural Home Phone Work Phone Cell Phone

ADLS IADLS

 Bathing Walking/Mobility Meal Preparation Use of Telephone

 Dressing Eating Shopping Laundry/Housekeeping

 Toileting Money Management Medication Mgmt/Treatment

 Transfer Transportation

VII. CAREGIVER SERVICE PLAN

Recipient 

No.

Service

Code Provider Name Units Per

Total

Units

Start

Date

End 

Date

Discharge 

Code

Kansas III-E Caregiver Assessment Plan 20
KDOA Form SS-025 (10/01/10)

VIII. ADULT CARE RECIPIENT #2:

CAREGIVER for Adult - Relationship to Recipient: Husband Wife

Daughter/Daughter-in-law Son/Son-in-law Other Relative Non-relative

Qualifying Care Recipient: Senior 60 years or older Adult w/Alzheimer’s <60 Disabled Adult < 60

ADULT CARE RECIPIENT #2 INFORMATION Male

Female

Name (First, Middle, Last DOB Recipient SSN

Address City County State Zip Code

 Urban

 Rural Home Phone Work Phone Cell Phone

ADLS IADLS

 Bathing Walking/Mobility Meal Preparation Use of Telephone

 Dressing Eating Shopping Laundry/Housekeeping

 Toileting Money Management Medication Mgmt/Treatment

 Transfer Transportation

IX. ADULT CARE RECIPIENT #3:

CAREGIVER for Adult - Relationship to Recipient: Husband Wife

Daughter/Daughter-in-law Son/Son-in-law Other Relative Non-relative

Qualifying Care Recipient: Senior 60 years or older Adult w/Alzheimer’s <60 Disabled Adult < 60

ADULT CARE RECIPIENT #3 INFORMATION Male

Female

Name (First, Middle, Last DOB Recipient SSN

Address City County State Zip Code

 Urban

 Rural Home Phone Work Phone Cell Phone

ADLS IADLS

 Bathing Walking/Mobility Meal Preparation Use of Telephone

 Dressing Eating Shopping Laundry/Housekeeping

 Toileting Money Management Medication Mgmt/Treatment

 Transfer Transportation

X. NOTES:

Kansas III-E Caregiver Assessment Plan 21
KDOA Form SS-025 (10/01/10)

III-E CAREGIVER ASSESSMENT PLAN 

INSTRUCTIONS 

GENERAL 

Do not use this form if you are providing “Information” or “Assistance” only. 

Complete the entire III-E Caregiver 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 

Complete all information in Section I.

SECTION II: CAREGIVER CATEGORY 

Check the funding category for which the applicant is applying. If applying for more than one category, separate 

forms must be completed. 

Check “Grandparent” if caring for Child/Children < 19 years of age or disabled adult(s) 19 - 59 years of age, 

regardless of the caregiver’s relationship to the child or disabled adult. 

 

SECTION III: CAREGIVER INFORMATION 

Complete all “Caregiver” information, including a complete address and Urban/Rural designation. 

The Ethnicity and Race categories reflect 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 

Complete this section only if “Grandparent” Caregiver Category checked. 

List the total number of qualifying 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). 

SECTION V: CAREGIVER FOR ADULT 

Check the applicable “Relationship”. A separate section for each adult care recipient is required. 

SECTION VI: ADULT CARE RECIPIENT #1 INFORMATION: 

Complete all “Adult Care Recipient #1” information.

SECTION VII: CAREGIVER SERVICE PLAN 

Enter Care Recipient No. (e.g. Recipient #1, 2, or 3) for applicable adult or leave column blank if “Grandparent 

caring for grandchild(ren) < 19 years of age” Caregiver; 

Enter Service Code; Provider Name; Units; Per (day or week); Total Units (per month); Service Start Date; and 

Service End Date. 

Enter a Discharge Code when the Caregiver no longer receives a service. 

SECTION VIII: ADULT CARE RECIPIENT #2 

Complete all “Adult Care Recipient” information for a second adult if two or more adults are care recipients.

SECTION IX: ADULT CARE RECIPIENT #3

Complete all “Adult Care Recipient” information for a third adult if three or more adults are care recipients. 

(Additional forms may be used if more than three adults are care recipients.)

SECTION X: NOTES 

This section is available for the Interviewer 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. 

Kansas III-E Caregiver Assessment Plan 22
KDOA 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 20th day of the month 

following the month in which services 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 20th day of the 

month following the month in which services were provided.

Following is a list of required KAMIS fields: 

SECTION 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 following information must be entered 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): 

Relationship to Recipient 

Qualifying Care Recipient 

SECTION X NOTES: 

None

Kansas III-E Caregiver Assessment Plan 23
 PAF 4016 

 02/2015 

INSTRUCTIONS FOR COMPLETING NATIONAL FAMILY CAREGIVER 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. Section A: Agency/Organization Information 

Enter Date of Request/Referral, Method of Contact, Assessor Name, Agency Name 

2. Section B: Initial Screening and Intake 

Choose appropriate category for Client status. If client is a Family Caregiver, enter the 

relationship to the Qualifying Individual. 

3. Obtain and record qualifying individual’s identifying information. 

4. Section C: Caregiver Information 

Obtain and record 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. Section D: Determine Client eligibility for priority status. Check Appropriate box. 

Greatest Economic Need, Greatest Social Need, and individual providing care for person 

who has developmental disability are determined based upon self-reported data. 

a. Greatest Economic Need- Ask for the number of persons in the Client’s 

household. Then check the chart below and ask whether the annual income more

or less than the amount in the corresponding column. 

2015 HHS Poverty Guidelines1

Size of Family Unit 48 Contiguous States & 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

SOURCE: Federal Register, Vol. 79, No. 14, January, 22, 2014, pp. 3593-3594

Louisiana Instructions and Intake Assessment Form 24
 PAF 4016 

 02/2015 

For each additional person, add $4,160

b. Greatest Social Need - Determine whether the Client has any of the following problems: 

 physical and mental disabilities; 

 language barriers (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 

independently. 

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 qualifying 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 agency on aging to the home of the qualifying individual. 

9. If Client needs Respite Care, Material Aid, Personal 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.

Louisiana Instructions and Intake Assessment Form 25
Name of Client (Caregiver): ID#: 

 PAF 4016 

 02/2015 

NATIONAL FAMILY CAREGIVER SUPPORT PROGRAM 

INTAKE ASSESSMENT FORM 

SECTION A: AGENCY/ORGANIZATION INFORMATION

Date of Request or Referral: ______________ Method of Contact: telephone  face-to-face

Month/Day/Year other

Assessor Name: _________________________ Agency Name: ________________________________

SECTION B: INITIAL SCREENING AND INTAKE

PERSON PROVIDING ANSWERS AND INFORMATION FOR ASSESSMENT:

 Caregiver  Friend/neighbor  Legal guardian or surrogate decision-maker

 Family member  Other professional (e.g. care manager) 

PRIMARY LANGUAGE: 

 English  Spanish  French  Other _________________________________

QUALIFYING INDIVIDUAL (Person receiving care): 

Name: ________________________________ Address:___________________________________

State: ____________ Zip Code: __________ Parish: ______________ Phone: ________________ 

Social Security Number: _______________________ Date of Birth: _________________

Caregiver by Relationship  Husband  Wife  Son/Son-in-law  Daughter/Daughter-in-law

 Other Relative  Non-Relative 

SECTION C: CAREGIVER INFORMATION

Social Security Number:--

Louisiana Identification Number: 

Last Name: _____________________ First Name: ___________________________ MI: ________

Address:___________________________ Apt. #: ____________ Parish: ______________________

State: ________ Zip Code: _________ Telephone (Home): ____________ Work: _______________

DOB: ___________________________ Rural/Isolated:  Yes  No

 Month/Day/Year

Gender:  Male  Female

Race:  White (Alone)

 Black or African American (Alone) 

 American Indian/Alaskan Native (Alone) 

 Native Hawaiian/Other Pacific Islander 

 Asian (Alone)

 Declined to Respond 

 Other_____________________ 

Marital Status:  Never Married

 Married 

 Partner/Significant Other

 Widowed

 Separated

 Divorced

Louisiana Instructions and Intake Assessment Form 26
Name of Client (Caregiver): ID#: 

 PAF 4016 

 02/2015 

Ethnicity: Hispanic/Latino Not Hispanic/Latino 

NATIONAL FAMILY CAREGIVER SUPPORT PROGRAM 

INTAKE ASSESSMENT FORM (CONTINUED) 

Name of Client (Caregiver): ___________________________ ID #: _____________ 

SECTION D: Priority Status (check all that apply)

 Client is an older individual in greatest economic need

 Client is an older individual in greatest social need

 Client is an older individual providing care and support to person who has a developmental disability

Eligibility for Respite Care, Personal Care, Material Aid and Sitter Service 

(check all that apply – at least one must apply to be eligible):

 The qualifying individual is unable to perform at least two of the following activities without 

substantial human assistance, including verbal reminding, physical cueing, or supervision: bathing; 

dressing; toileting; transferring; walking: eating.

 The qualifying individual has a 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.

Describe the type of assistance needed {continue on supplemental sheet(s)}:

Directions to Home of Qualifying Individual {continue on supplemental sheet(s)}:

-------------------------------------------------------------------------------------------------------------------------------

I have received a copy of the grievance procedure and contribution policy. 

_________________________________ _____________________________ 

Louisiana Instructions and Intake Assessment Form 27
Name of Client (Caregiver): ID#: 

 PAF 4016 

 02/2015 

Date Signature of Caregiver

_________________________________ ______________________________ 

Date Signature of Intake Worker

Family Caregiver Support Program Score Sheet

1. The caregiver's income level is at or below the federal poverty line. 

 No = 0 Yes = 1 

2. The caregiver has "greatest social need." No = 0 Yes = 1 

3. The caregiver is 60 years of age or older and providing care and support to 

 person that has a developmental disability. No = 0 Yes = 1 

4. Age of caregiver: 

 Under 60 = 0 60 -74 years of age = 1 75 years of age or older = 2 

5. How does the caregiver rate her/his overall health?

 Good = 0 Fair = 1 Poor = 2

6. For how many qualifying individuals is this caregiver the primary 

 caregiver? (One point for each qualifying individual)

7. How many hours of direct care on average each day does the caregiver 

 provide to the qualifying individual?

8 hours or less = 0 9 - 16 hours= 1 17 - 24 hours = 2

8. Is the caregiver employed? 

 No = 0 Part-time = 1 Full- time (35 or more hours/week) = 2 

9. With how many of the following activities of daily living does the caregiver 

 provide assistance to the qualifying individual? (one point for each - 

 circle all that apply) 

BATHING DRESSING TOILETING TRANSFERRING WALKING EATING 

10. Does the qualifying individual receive assistance with any of the 

 activities in question 9 from any other source? Yes = 0 No = 1

11. Caregiver Stress Level: 2Little/No Stress = 0 Mild/Moderate = 1 

Moderate/Severe Stress = 2 Severe Stress = 3 

TOTAL SCORE

 

2From Caregiver Stress Interview

Louisiana Instructions and Intake Assessment Form 28
Name of Client (Caregiver): ID#: 

 PAF 4016 

 02/2015 

Louisiana Instructions and Intake Assessment Form 29
Name of Client (Caregiver): ID#: 

 PAF 4016 

 02/2015 

CAREGIVER STRESS INTERVIEW 

Read to Caregiver: The following is a list of statements which reflect how people sometimes feel when taking 

care of another person. After each statement, indicate how often you feel that way: never, rarely, sometimes, 

quite frequently, or nearly always. There are no right or wrong answers. 

QUESTION 

 

Never

(0)

Rarely

(1)

Sometimes

(2)

Quite 

Frequently

(3)

Nearly

Always

(4)

Score

1. Do you feel that your relative asks for 

 more help than he/she needs?

2. Do you feel that because of the time you 

 spend with your relative that you don’t 

 have enough time for yourself?

3. Do you feel stressed between caring for 

 your relative and trying to meet other 

 responsibilities for your family or work?

4. Do you feel embarrassed over your 

 relative’s behavior?

5. Do you feel angry when you are around 

 your relative?

6. Do you feel that your relative currently 

 affects your relationship with other family 

 members or friends in a negative way?

7. Are you afraid of what the future holds for 

 your relative?

8. Do you feel your relative is dependent 

 upon you?

9. Do you feel strained when you are around 

 your relative?

10. Do you feel your health has suffered 

 because of your involvement with your 

 relative?

11. Do you feel that you don’t have as much 

 privacy as you would like because of your 

Louisiana Instructions and Intake Assessment Form 30
Name of Client (Caregiver): ID#: 

 PAF 4016 

 02/2015 

QUESTION 

 

Never

(0)

Rarely

(1)

Sometimes

(2)

Quite 

Frequently

(3)

Nearly

Always

(4)

Score

 relative?

12. Do you feel that your social life has 

 suffered because you are caring for your 

 relative?

13. Do you feel uncomfortable about having 

 friends visit you because you are caring for 

 your relative?

14. Do you feel that your relative seems to 

 expect you to take care of him/her as if you 

 were the only one he/she could depend on?

15. Do you feel that you don’t have enough 

 money to care for your relative in addition 

 to the rest of your expenses?

16. Do you feel that you will be unable to take 

 care of your relative much longer?

17. Do you feel you have lost control of your 

 life since your relative’s illness?

18. Do you wish you could just leave the care 

 of your relative to someone else?

19. Do you feel uncertain about what to do 

 about your relative?

20. Do you feel you should be doing more for 

 your relative?

21. Do you feel you could do a better job in 

 caring for your relative?

22. Overall, do you feel burdened caring for 

 your relative?

CAREGIVER STRESS LEVEL: 2

2 The caregiver 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 = Severe Stress 

Louisiana Instructions and Intake Assessment Form 31
Name of Client (Caregiver): ID#: 

 PAF 4016 

 02/2015 

CLIENT SERVICE RECORD 

(copy as needed)

Approved Services Service Provider Beginning 

Service Date

Ending Service 

Date

Louisiana Instructions and Intake Assessment Form 32
Name of Client (Caregiver): ID#: 

 PAF 4016 

 02/2015 

Approved Services Service Provider Beginning 

Service Date

Ending Service 

Date

SUPPLEMENTAL SHEET

(copy as needed)

Louisiana Instructions and Intake Assessment Form 33
Name of Client (Caregiver): ID#: 

Louisiana Instructions and Intake Assessment Form 34
Name of Client (Caregiver): ID#: 

NATIONAL FAMILY CAREGIVER 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 subaverage general intellectual function existing 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; selfdirection; 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). 

Signature Date

Louisiana Instructions and Intake Assessment Form 35
FCSP v1.0.1

SECTION I: REFERRAL SOURCE

REFERRAL SOURCE

How did you complete 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.

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SECTION II: CAREGIVER CONTACT INFORMATION AND 

CAREGIVING SITUATION

CONTACT INFORMATION

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 37
Who else is the caregiver responsible for? (Check all that 

apply)

Child(ren)

Domestic Partner/Significant 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)

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Massachusetts Caregiver Assessment Tool 2015 38
SECTION III: CARE RECIPIENT'S CHARACTERISTICS

CARE RECIPIENT'S CHARACTERISTICS

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

How did the caregiver explain the care recipient's present 

physical/mental health? Check all that apply.

Alzheimer's disease

Arthritis

Cancer

Dementia other 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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Who helps with the care recipient's psychosocial support?

Private pay

Caregiver

Independent

Non-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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Who helps with meal preparation?

Private pay

Caregiver

Independent

Non-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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SECTION IV: CAREGIVER SERVICE ASSESSMENT

A. CAREGIVER'S NEEDS

What are the caregiver'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

Does the caregiver feel s/he has the necessary ability and 

knowledge 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

Does the caregiver have a back-up plan for her/himself in 

the event s/he unexpectedly could not assist the care 

recipient?

No

Yes

If the caregiver has a back-up plan, is it adequate?

No

Yes

Not Applicable

If caregiver doesn't have back-up plan, would they like to 

develop one?

No

Yes

Not 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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When providing care to the care recipient, what 

situations are stressful for the caregiver? 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

Education/skill building (e.g. managing behavior, personal 

care)

End of Life Issues

Friendly Visitor

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.

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Was a caregiver action plan developed after the 

assessment was completed?

Yes

No

Signature:

Date

______/______/____________

Title : Date 

Title : Date 

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MBA 01.28.14 Rev’d

MBA Title III-E Caregiver 

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 ScreenSM

Minnesota Title III-E Caregiver Questionnaire 45
Part I. Caregiver Program Registration

Please complete this form to the best of your ability. Shaded areas are for office use only.

Contact Date

 / /

Status AAA Region NAPIS ID Number

 - -

Section A. Basic Demographics

Last Name: First Name: Middle Initial:

Lives in Rural Area (Circle One):

Yes ⁭ No

Gender: ⁮ Female ⁮ Male

 ⁮Unspecified

Date of Birth:

 / /

Address: Address #2:

City: State: Zip Code: County:

Home Phone:

( )

Mobile Phone:

( )

Work Phone:

( )

Section B. Social History

Race (Circle one): ⁯ American Indian/Alaskan ⁯ Asian

 White Hispanic White not Hispanic 2 or More Races

⁯ Black/African American ⁯ Native Hawaiian/Pacific Islander ⁯ 

Other

Ethnicity (Circle one)

⁮ Hispanic or Latino

⁮ Non-Hispanic

Section C. Care Receiver

What is the care receiver’s name?

(Last)________________________________ (First)_______________________________ (Middle Initial)______

What is the care receiver’s date of birth? ______/_________/________

What is your relationship to the care receiver? (Circle one)

 ⁮ Husband ⁮ Wife ⁮ Son/Son-in-law ⁮ Daughter/Daughter-in-law ⁮ Other Relative

 ⁮ Non-Relative ⁮ 

What is the approximate household income of the care receiver? (Circle one)

1 person in a single or multiple, non-spousal household

Under $973/month $973 to $1,459/month $1,460 to $1,945/month More than $1,945/month 

2 person spousal household

Under $1,311/month $1,311 to $1,966/month $1,967 to $2,622/month More than $2,622/month 

Section D. Use of Information

I understand that the information I am providing on this form is for registration purposes. The information 

will be used by the Area Agency on Aging and the Minnesota Board on Aging to create statistical reports 

and may be used by service providers to help identify other services from which I may benefit. This 

information will not be released to anyone other than the above mentioned parties in a way that will 

identify me as an individual unless I sign a separate consent for that purpose.

Signature: ___________________________________________ Today’s Date: ____________________

Minnesota Title III-E Caregiver Questionnaire 46
Part II. Caregiving Questions 

What is your most immediate need or concern?

How did you hear about this agency/organization? 

 Brochure Newspaper Friend or acquaintance Internet Website

Doctor/health clinic Community service/program Other

Are you currently employed? (Please describe)

 Working full-time Working part-time Not Currently Employed 

 

Do you live in the same household as the person needing care?

 Yes 

 No If not, what is the distance between households? _____ miles 

Is there anyone else living with you or <NOP> that needs your care or time (e.g., 

minor children, parent, or other dependent)?

How would you describe your own health?

 

 Excellent Good Fair Poor 

What illnesses or medical problems do YOU have that limit your ability to provide care, 

and do what you need to do? (e.g., chronic pain, diabetes, emphysema, Parkinson’s, 

physical disabilities, mental illness)

Do you have difficulty getting a good night’s sleep, 3 or more times per week?

 Yes 

No

Sometimes 

Notes:

Minnesota Title III-E Caregiver Questionnaire 47
Activities of Daily Living

[Note: assistance with two or more ADLs or needs supervision for respite and supp.

services]

Can <NOP> walk around inside without 

any help? Yes No 

Can <NOP> bathe or shower without any 

help? Yes No 

Can <NOP> sit up or move around in 

bed without any help? Yes No 

 Can <NOP> use the toilet without any 

help? Yes No 

Can <NOP> comb their hair, shave, wash 

their face, or brush their teeth without 

any help? Yes No 

Can <NOP> dress without any help?

Yes No 

Can <NOP> get in and out of bed or 

chair without any help? Yes No 

Can <NOP> eat without any help?

Yes No 

Need for Supervision:

Does <NOP> have issues with memory, thinking, or the ability to make decisions that 

result in the need for supervision? Yes No 

 

Is <NOP> a Veteran? Yes No

If Yes, do you or <NOP> receive any Veteran’s benefits? Please describe:

Does <NOP> receive assistance from the county or Medical Assistance Yes No

(ie., does NOP have a county worker?)

What health problems or medical conditions does <NOP> have that need to be 

managed? 

What is your comfort level with <NOP’s> medications or treatments?

Are you satisfied with the amount of information you have been given so far about 

<NOPs> disease or condition (e.g., dementia, stroke, Parkinson’s, etc.)? Or, do you 

have questions that haven’t been addressed yet?

Yes No

Please describe: 

Minnesota Title III-E Caregiver Questionnaire 48
What types of UNPAID help or care are you or <NOP> currently receiving from friends, 

family, neighbors, people from church, or others in the community? (List person, 

relationship to CG or CR/type of help/how often)

Who would you call in an emergency? 

Do you have plans in place for caregiving in the event of an emergency or health care 

crisis (e.g., who would help/type of help, etc.)? 

Do you have concerns about <NOPs> safety? (e.g., falls, driving, cooking, wandering, 

alcohol or drug use, fire arms, self-harm or harm to you)

Yes No 

Please describe: 

Are there issues that might cause you to consider a higher level of care for <NOP> or a 

transition into assisted living or a nursing home? (e.g., worsening dementia, falls, 

incontinence, your physical health, financial or emotional strain, etc.)

Have you and <NOP> done any planning for the future? (Check all that apply) 

(CG = caregiver, NOP = older adult)

Advanced healthcare directive CG NOP

Power of attorney CG NOP

A will/trust/or estate planning CG NOP

Guardianship/Conservatorship CG NOP

Notes:

Minnesota Title III-E Caregiver Questionnaire 49
Part III: Caregiver Screen* 

<Please 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. As a result of assisting <NOP>, to what extent have the following aspects of your 

life changed?

To what degree have your care

responsibilities ... 

Not at 

all

A 

little

Moderately A lot A 

great 

deal

(a) Caused conflicts with your relative? 1 2 3 4 5

(b) Decreased time you have to

yourself?

1 2 3 4 5

(c) Created a feeling of hopelessness? 1 2 3 4 5

(d) Given your life more meaning? 1 2 3 4 5

(e) Increased the number of 

unreasonable requests made by your 

relative?

1 2 3 4 5

(f) Kept you from recreational 

activities?

1 2 3 4 5

(g) Made you nervous? 1 2 3 4 5

(h) Made you more satisfied with your 

relationship?

1 2 3 4 5

(i) Caused you to feel that your relative 

makes demands over and above what 

he/she needs?

1 2 3 4 5

(j) Caused your social life to suffer? 1 2 3 4 5

(k) Depressed you? 1 2 3 4 5

(l) Given you a sense of fulfillment? 1 2 3 4 5

(m) Made you feel you were being taken 

advantage of by your relative?

1 2 3 4 5

(n) Changed your routine? 1 2 3 4 5

(o) Made you anxious? 1 2 3 4 5

(p) Left you feeling good? 1 2 3 4 5

(q) Increased attempts by your relative 

to manipulate you?

1 2 3 4 5

(r) Given you little time for friends and 

relatives?

1 2 3 4 5

Minnesota Title III-E Caregiver Questionnaire 50
(s) Caused you to worry? 1 2 3 4 5

(t) Made you enjoy being with your 

relative more?

1 2 3 4 5

(u) Left you with almost no time to 

relax?

1 2 3 4 5

(v) Made you cherish your time with 

your relative?

1 2 3 4 5

*Montgomery Burden Scale. Source: 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. The following is a list of the ways you may have felt or behaved recently. For 

each statement, indicate how many days you have felt this way during the 

past week. 

DURING THE PAST WEEK: Rarely or 

none of the

time (less 

than 1 day)

Some or a 

little of the 

time

(1-2 days)

Occasionally 

or a moderate 

amt. of time 

(3-4 days)

All of the 

time (5-7 

days)

a. I was bothered by things 

that don’t usually bother 

me

1 2 3 4

b. I had trouble keeping my 

 mind on what I was doing

1 2 3 4

c. I felt depressed 1 2 3 4

d. I felt that everything I did 

was an effort

1 2 3 4

e. I felt hopeful about the 

future

4 3 2 1

f. I felt fearful 1 2 3 4

g. My sleep was restless 1 2 3 4

h. I was happy 4 3 2 1

i. I felt lonely 1 2 3 4

j. I could not “get going” 1 2 3 4

Source: Center for Epidemiological Studies Depression Scale (CES-D)

Minnesota Title III-E Caregiver Questionnaire 51
Sum Baseline CES-D Score: 26-40 High*; 19-25 Medium*; 10-18 Low

 * If scores medium or high a referral to primary care physician is recommended. 

Part IV. Closing Questions 

How much time each week do you have to yourself, to get things done, to socialize with 

family/friends, relax, or for other purposes?

What would you do more of if you had more time away from caring for <NOP>?

After our conversation today, what do you think are the most immediate issues or 

concerns that need to be addressed or that you need some assistance with? What 

things would you like us to address first?

Notes/Additional Questions

Minnesota Title III-E Caregiver Questionnaire 52
Part V. Sample Caregiver Plan 

Name Caregiver ID 

Date of Plan 

Initial Follow-up 3 Month 6 Month 9 Month 12

Month

Goals: <At least one goal should focus on caregiver’s health> 

Goal: 

Desired Outcome:

Milestone:

Goal: 

Desired Outcome:

Milestone:

Goal: 

Desired Outcome:

Milestone:

Caregiver Consultant Responsibility

Caregiver Responsibility

Caregiver Consultant 

Name

Signature Date

Caregiver Name Signature Date

Minnesota Title III-E Caregiver Questionnaire 53
Live Well At Home Rapid Screen© – Family Caregiver

Screen Date: ____________ 

1. Does <name of older person (NOP)> need help from someone else 

to do the following? 

 a) Walking b) Getting out of bed/chair c) Going to the bathroom 

 d) Bathing e) Dressing f) Eating

If 2 or more circled  SCORE = 2

2. During the last 6 months, has <NOP> had a fall that caused 

injuries or engaged in behavior problems such as wandering, 

verbal or physical disruption, or other behaviors that require 

supervision? Yes No

NOTE: “Injuries” means fracture or joint dislocation, head injuries resulting 

in loss of consciousness and hospitalization, joint injuries that led to 

decreased activity, internal injuries that led to hospitalization OR 3 or more 

of any falls

IF YES circled  SCORE = 2

3. Does <NOP> have a family member/friend give help when she/he 

needs it? Yes No

If NO circled  SCORE = 2

4. Do you feel overwhelmed or stressed because of the care you 

provide for <NOP>? Yes No

If YES circled  SCORE = 2

5. Have you/<NOP> thought about moving <NOP> to other housing? 

Yes No

If YES, where has <NOP> considered moving to? 

If answered NURSING HOME or ASSISTED LIVING (i.e., Housing 

With Services)  SCORE = 2

6. Does <NOP> live alone? Yes No

If YES circled  SCORE = 1

7. Do you or your family have concerns about <NOP’s> memory, 

thinking, or ability to make decisions? 

If YES, are you: Very concerned Somewhat concerned 

If VERY CONCERNED circled  SCORE = 2

If SOMEWHAT CONCERNED circled  SCORE = 1

TOTAL SCORE (Sum of Scores For Items 1 Through 7) =

Score and Risk Category

0 = No Risk 1 = Low Risk 2 = Moderate Risk 3 and Higher = High Risk 

Minnesota Title III-E Caregiver Questionnaire 54
Caregiver Support - Initial Assessment 1.2.2015 Page 1 of 6 

Initial Assessment

Date of Initial Contact:___________ Name of Interviewer:________________ Date of Assessment:_________ 

Caregiver Name________________________________________ 

I prefer to be addressed as:______________________________________________________________________ 

Address: _________________________________________________________________________________

Mailing address (if different from above): _______________________________________________________ 

Daytime phone:________________ Alt phone:______________ Email:______________________________ 

What is the best method to contact you? Daytime phone Alt phone Email 

Age of Caregiver: DOB__ /__ /____ or Under 60 60-74 75-84 85+ Unknown 

Gender of Caregiver: Male Female 

Name of Individual you provide care for:____________________________________________________ 

Address (if living in a different location): ______________________________________________________ 

Length of time you have been caring for this person: ______________________________(in years and months) 

How many hours do you usually spend providing care for this individual? _______ Day Week 

Who else lives with you, the primary caregiver?__________________________________________________ 

How many adults 18 and over? ___________ How many younger than 18?_______________ 

Are you caring for anyone else? (i.e. children, other adults, etc.) No Yes_________________________ 

Are there any communication issues, or do you need an interpreter? No Yes If yes, what is needed: 

________________________________________________________________________________________

Who is your emergency contact? ______________________________________________________________ 

Who else lives with the person you are caring for? ________________________________________________ 

Name:___________________________________ Relationship: ____________________________ 

Name:___________________________________ Relationship: ____________________________ 

Name:___________________________________ Relationship: ____________________________ 

New Hampshire Initial Caregiver Assessment 55
Caregiver 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? 

Yes 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: ____________________________________________________________________________________ 

__________________________________________________________________________________________

Referral Source: 

How were you referred to the program? Hospital Nursing or Rehab An individual 

Home Health Agency/VNA Adult Day Program Self-referral Alz. Assoc. Other

Section 1: Caregiver Specific Information 

Providing the information below regarding finances, ethnicity and race is optional and is not required to determine 

eligibility. Only responses without personal identifying information will be shared. The U.S. Administration on Aging 

requires the collection of this information to gain a better understanding of the situations and needs of family 

caregivers nationwide.

Annual Income:

$0-20,000

$20,001-40,000

$40,001-60,000

Over $60,000

Unknown

Marital Status of Caregiver:

Never Married 

Divorced

Married 

Living with Partner

Widowed

Unknown

Ethnicity of Caregiver:

Hispanic Origin Non-Hispanic Unknown

Relationship of Caregiver to Care Recipient: (The 

caregiver is the ______of the care recipient)

Race of Caregiver:

White Alone 

Black/ African Amer.

Amer. Ind./Alaska Nat. 

Asian 

Nat. Hawaiian/Pacific Islander

Some other race 

Two or more races 

Unknown

Husband 

Wife

Partner

Son/Son-in-Law

Daughter/Daughter-in-Law

Other Relative 

Non- Relative

Unknown 

Financial: 

Are you currently employed? Yes ___ Part-time ___Fulltime No 

If not currently working, what is the main reason you do not work? 

Retired Disabled Unable to work temporarily 

On layoff On family leave Left job to provide care

Are you receiving some type of payment to provide care to this individual? ** Yes No

Which of the following 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

Are there medications; supplies or treatments that either you and/or the individual you are caring for should 

have, but cannot afford to buy? Yes No 

In the next few months, do you anticipate new expenses that will be necessary in order to help keep the 

individual you are caring for at home (renovations, wheelchair, or assistive equipment)? Yes No

New Hampshire Initial Caregiver Assessment 56
Caregiver 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 legal guardian Yes No

Special POA for health-care Yes No

DPOA for finances Yes No

A living will Yes No

EMS/DNR directives Yes No

A funeral plan Yes No 

A burial plan Yes No

Do you need assistance developing any of the above? Yes No _________________________________ 

Caregiving Experiences & Strengths: 

Frequently 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 that you bring to your caregiving role? _______________________ 

_________________________________________________________________________________________ 

How would you say your overall health is? Poor Fair Good Very Good Excellent 

Do you feel you have a good understanding of the individual’s condition? _________________________

Are you comfortable asking other people to be involved in or help in caregiving? Yes No 

__________________________________________________________________________________________

Back Up Plan:

Is there anyone else assisting you with caregiving? Yes No _________________________________ 

Do you currently have anyone available to provide temporary emergency care when you are unable to? 

Yes 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 have any concerns about the safety of the individual you are caring for? falling wandering 

Other______________________________________________________________ No concerns

Do either you or the individual you care for feel at risk of verbal abuse, physical abuse, neglect, selfneglect or financial exploitation by another person? _______________________________________________ 

New Hampshire Initial Caregiver Assessment 57
Caregiver Support - Initial Assessment 1.2.2015 Page 4 of 6 

Environmental: (interviewer’s observations)

Is there safe access to living areas (stairs, steps, doorways)? Yes No_________________________

Is there sufficient heating/air conditioning? Yes No_______________________________________

Are there concerns about electrical / fire hazards? Yes No _________________________________

Is there proper egress/escape plan in case of fire? Yes No _________________________________

Are there concerns about yard work/snow removal? Yes No ________________________________

Supports and Services:

Does the individual you care for receive any services on a regular basis such as: Homemaker 

Home Health or VNA VA Choices for Independence Other:_________________________

If yes, can you specify the health provider? _______________________________________ 

Self-Care:

Do you attend a support group, educational, or training sessions? Yes If yes, is it helpful? Yes No 

Notes:________________________________________________________________________________

What you like to see happen over the next six months to a year that would benefit you? (i.e. activities you may 

have set aside that you used to enjoy)____________________________________________________

___________________________________________________________________________________________________________ 

Do you feel: Never Rarely Sometimes

Quite 

Often

Nearly 

Always 

...that because of the time you spend with (care recipient’s

name) that you don’t have enough time for yourself?

...stressed between caring for (care recipient’s name) and 

trying to meet other responsibilities (work/family)?

...strained when you are around (care recipient’s name)?

...uncertain about what to do about (care recipient’s

name)?

Source: Zarit 4-item Caregiver Burden screen; Michel Bédard et.al., The Gerontologist 41:652-657 (2001) 

Section 2: Care Recipient Specific Information

Gender of Care Recipient: Male Female 

Age of Care Recipient*(required): DOB__ /__ /____ Under 60 60-74 75-84 85+

Providing the information below is helpful in determining other programs you may be eligible for:

Annual Income:

$0-20,000 $20,001-40,000

$40,001-60,000 Over $60,000

Unknown

Assets: (Note: excludes primary home and vehicle)

$0-5,000 $5,001-10,000

$10,001-20,000 $20,001-30,000

Over $30,000 Unknown

New Hampshire Initial Caregiver Assessment 58
Caregiver Support - Initial Assessment 1.2.2015 Page 5 of 6 

The Physical and Mental Status of the Individual Being Cared For:

Instrumental Activities of Daily Living (This information is helpful in identifying potential community supports.) Yes No

A.Meal Preparation: Care recipient can prepare breakfast and light meals

B.Telephone: Can use telephone as necessary, e.g., able to contact people in an emergency. 

C.Light Housework: can do light housework; washing dishes, dusting (daily basis), making bed. 

D.Managing Finances: Can manage own finances; banking; handling checkbook; paying bills. 

E. Medication: Can take medication on time with correct dose, without assistance.

F. Transportation: Needs transportation and/or escort to medical, dental appointments, necessary 

engagements, or other activities or needs

 Yes No 

Has the individual been hospitalized or seen in the Emergency Room recently? 

Definitions:

Independent: can accomplish with or without assistive devices—No help needed.

Needs assistance, or done with help: Individual involved in activity, but help (including supervision, reminders, 

and/or physical “hands-on” help) is needed.

Dependent or done by others: 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

Activities of Daily Living Ind. Asst. Dep.

Transfers: How individual moves to/from: bed, chair, wheelchair, or standing 

Walking/Mobility: How individual walks or moves between locations in his/her 

room and other areas on same floor. If in wheelchair, self-sufficiency once in chair. 

Dressing: How individual puts on, fastens, and takes off all items of clothing

Eating: How individual eats and drinks (regardless of skill)

Bathing /Personal Hygiene: How individual takes full-body bath/shower, sponge 

bath, and transfers in/out of tub/shower; maintains personal hygiene, including

combing hair, brushing teeth, shaving, washing/ drying face, & hands.

Toilet Use: How individual uses the toilet; transfers on/off toilet, cleans self, adjusts 

clothes; occasionally incontinent; frequently incontinent; or incontinent all of the 

time.

Cognition: Yes No

1. Individual has a Doctor’s diagnosis of Alzheimer’s disease or other type of 

dementia. 

2. It is no longer safe for the individual to be left alone. 

3. The individual is no longer able to follow through with reminders or prompts. 

 How many hours each day can the individual safely be left alone? _____ Hours 

_______________________________________________________________________________________ 

_______________________________________________________________________________________ 

New Hampshire Initial Caregiver Assessment 59
Caregiver Support - Initial Assessment 1.2.2015 Page 6 of 6 

Assistance Note: Check the services the caregiver has used, or might benefit from, if available. 

Have Used Could Use Have Used Could Use

Nursing care at home Training on providing care

Personal Care Counseling

Homemaker services Transportation

Chore services Home Modifications

Adult Day Occupational Therapy

Financial/Medical assistance Assistive Technology

Legal assistance Fuel Assistance

Respite-in home Home Repairs/Safety

Respite -Facility Alternative Housing

Support Group Veteran’s Benefits

Home Delivered Meals Other:

How might these services be paid for?______________________________________________________ 

Would information on any of the following areas be helpful to you? 

Medicare counseling Yes No 

Long Term Care Options Yes No

LTC Insurance Yes No 

Pharmacy Benefits Yes No

Education or training on how to care for yourself as a caregiver? Yes No

Opportunity to talk with a group of people in a similar situation, such as a support group? Yes No

Are there any other issues that you are concerned about that we didn’t cover?

_______________________________________________________________________________________ 

_______________________________________________________________________________________ 

*************************************************************************************** 

Notes:____________________________________________________________________________________ 

_________________________________________________________________________________________ 

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________ 

New Hampshire Initial Caregiver Assessment 60
Ohio Caregiver Assessment 61
Ohio Caregiver Assessment 62
Ohio Caregiver Assessment 63
Ohio Caregiver Assessment 64
Long Term Services and Supports Caregiver Assessment

Client name: _________________ 

Caregiver name: _________________

 Date: ______________

1. What is your relationship with the person receiving care? __________________________

2. How often are you consistently 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 responsibilities 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 future may bring and how I will manage it all Yes ____ No ____

• That I cannot provide the care that is necessary, Yes ____ No ____

Rhode Island Long Term Services and Supports Caregiver Assessment 65
• Behavioral issues of the person I care 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 information about

services? __________________________

Caregiver chooses not to participate _______.

Rhode Island Long Term Services and Supports Caregiver Assessment 66
South Carolina Eligibility for Title III-E Services 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
SD Caregiver Assmt

A. CAREGIVER/CARE RECEIVER PROFILE

A.1. CAREGIVER INFORMATION

What is 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)

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What is the CARE RECEIVER'S DATE OF BIRTH?

______/______/____________

What is the GENDER of the CARE RECEIVER?

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

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Is there a SECONDARY CAREGIVER who provides care on 

a regular basis?

0 - No

1 - Yes

What 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

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South Dakota Caregiver Assessment 73
B. OUTCOME

B OUTCOME

What SERVICES AND SUPPORT 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

Title : Date 

Title : Date 

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CAREGIVER FORM 2010a

Caregiver Assessment Instructions 

Eligibility 

The person receiving services under 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. 

Frail Guidelines 

To receive Respite or Supplemental services under the NFCSP, the care recipient must meet frail 

guidelines. Frail means, with respect to an older individual in a State, that the older 

individual is determined to be functionally impaired because the individual –

(A) (i) is unable to perform at least 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, stepgrandparents, and other older relative caregiver caring for a child.

 

Record Requirements 

For the NFCSP 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 

Tennessee Caregiver Assessment Instructions 75
- 2 -

I. Profile 

I.A. Caregiver Identification 

16. What is the client’s social security number (SSN)? – Enter the client’s social 

security number. If you have only collected 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 the primary local client identifier for the client. - The client identifier 

establishes a single file for each client for use 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 Profile 

5. What is the care receiver’s status? – This question is used to determine if a 

client (caregiver) is eligible to receive services under the NFCSP. Mark the 

appropriate status of the Care Receiver. 

7. Does the client have any other caregiving responsibilities? – List any other 

caregiving responsibilities that the client may 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. Describe any significant changes or events that have taken place in the client’s 

life during the last six (6) months? – If there have been changes, give brief 

description of those changes.

10. What contacts/services/supportive interventions have been provided for the 

client? – If the client is receiving services through other programs to assist them 

in providing care to the care recipient, list what services they are receiving and 

through which program they are receiving those services.

II. Caregiver Tasks 

II.A. Type of Service 

1. Does the client provide the care recipient with personal care? – Mark the 

appropriate response. Personal care includes help with bathing, dressing, 

toileting, shampooing hair, feeding, and transferring in and out of bed. 

Tennessee Caregiver Assessment Instructions 76
- 3 -

2. Does the client help the care recipient with housekeeping? – Mark the 

appropriate response. Housekeeping includes help with meal preparation, 

laundry, dishes, sweeping, vacuuming, mopping, and dusting.

3. Does the client help the care recipient manage his/her money? – Mark the 

appropriate response. Money management includes check writing, bank 

transactions, paying bills, investigating billing errors, and making investments.

4. Does the client help the care recipient with shopping and/or errands? – Mark 

the appropriate response. Shopping/Errands includes shopping for food, 

medicines, clothing, and personal items and running errands for the care 

recipient. 

5. Does the client help the care recipient with taking medication? – Mark the 

appropriate response. Medication management includes dispensing 

medications and supervising with taking medications.

6. Does the client provide the care recipient with transportation? – Mark the 

appropriate response. Transportation 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. Does the client provide the care recipient with other assistance? – Mark the 

appropriate response. Ask the client whether they provide any other assistance 

that has not already been addressed to the care recipient and include in 

comment section.

III. Impact of Caregiving

III.A. Caregiver Challenges 

Initial Assessment – If this is an initial assessment, you are trying to determine if 

these aspects of their lives have suffered since they began providing care for the 

care recipient. 

Reassessment – If this is a reassessment, you are trying to determine if these 

aspects of their lives have continued 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 changes since the initial assessment, then talk about what 

changes could be made to better help with their caregiving needs. 

1. How does the client rate his/her health? – Ask the client how their health is, 

using categories on the form. Make sure you record their opinion of how 

they would rate their health. This could be an indication of their potential 

to continue providing care. 

Tennessee Caregiver Assessment Instructions 77
- 4 -

3. Does the client feel that his/her health has suffered because of involvement 

with the care recipient? – Health problems of the client could prevent the 

caregiver from continuing to provide care. 

4. Does the client feel that the care recipient affects his/her relationship with 

family members/friends in a negative way? – The extent to which the client 

feels that their relationships 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. Does the client feel that his/her social life has suffered because s/he is 

caring for the care recipient? – The client my struggle with a diminished 

social 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. Does the client feel angry when s/he is around the client? – Client may feel 

angry about the increased dependency of the care recipient and the many 

demands on their time, energy, money, as well as other things. 

Tennessee Caregiver Assessment Instructions 78
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

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Tennessee Caregiver Assessment 79
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

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Tennessee Caregiver Assessment 80
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

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Tennessee Caregiver Assessment 81
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

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Tennessee Caregiver Assessment 82
Title : Date 

Title : Date 

Caregiver Form 2010a

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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 limitationsthat affect your ability to provide caregiving? Yes No

If yes, please explain:

4. Do you have any financial responsibilitiesrelated 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?

Utah Caregiver Assessment Form 84
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?

Utah Caregiver Assessment Form 85
Utah Caregiver Assessment Form 86
Utah Caregiver Assessment Form 87
Client Signature Date

Case Manager Signature Date

Case Manager Notes/Thoughts/Observations:

Utah Caregiver Assessment Form 88
 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 check 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

Utah Caregiver Assessment Form 89
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)

Utah Caregiver Assessment Form 90
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.

Utah Caregiver Assessment Form 91
Utah Caregiver Assessment Form 92
Utah Caregiver Assessment Form 93
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

 Retired

 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? 

Utah Caregiver Intake Form 94
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)

Utah Caregiver Intake Form 95
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 Raising a Grandchild

 Other Elderly Non-Relative

 Other Elderly Relative 

 Grandchild Other

Utah Caregiver Intake Form 96
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:

Utah Caregiver Intake Form 97
UAI Part A 1

VIRGINIA UNIFORM ASSESSMENT INSTRUMENT 

Date Screen: / / 

 Assessment: / / 

 Reassessment: / / IDENTIFICATION/BACKGROUND 

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:

 

 

 

 

 

 

Virginia Uniform Assessment Instrument 98
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 

 Friendly Visitor/Telephone Reassurance

 Habilitation/Supported Employee

 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 Attorney, 

 $ 9,500 - 10,999 ($ 792 - $ 916) 3 Representative Payee, 

 $ 7,000 - 9,499 ($ 583 - $ 791) 4 Other, 

 $ 5,500 - 6,999 ($ 458 - $ 582) 5

 $ 5,499 or Less ($ 457 or Less) 6 Do you receive any benefits or entitlements? 

 Unknown 9 No 0 Yes 1

Number in Family unit: Auxiliary Grant

Food Stamps

Optional: Total monthly family income: Fuel Assistance

General Relief

Do you currently receive income from...? State and Local Hospitalization 

No 0 Yes Optional: Amount Subsidized Housing

 Black Lung, 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: 

Virginia Uniform Assessment Instrument 99
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 Facility 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:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Virginia Uniform Assessment Instrument 100
UAI Part A 4

CLIENT NAME: Client SSN: 

FUNCTIONAL STATUS (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: 

Virginia Uniform Assessment Instrument 101
UAI Part B 5

CLIENT NAME: Client SSN: 

PHYSICAL HEALTH ASSESSMENT 

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)

Virginia Uniform Assessment Instrument 102
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 

Virginia Uniform Assessment Instrument 103
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) 

Virginia Uniform Assessment Instrument 104
UAI Part B 8

CLIENT NAME: Client SSN: 

PSYCHO-SOCIAL ASSESSMENT 

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: 

Virginia Uniform Assessment Instrument 105
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 

Virginia Uniform Assessment Instrument 106
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? 

 

 

 

 

 

 

Virginia Uniform Assessment Instrument 107
UAI Part B 11

CLIENT NAME: Client SSN: 

ASSESSMENT SUMMARY 

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): 

 

 

Virginia Uniform Assessment Instrument 108
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 #: 

Virginia Uniform Assessment Instrument 109
VT DAIL Full ILA11

VT DAIL Independent Living Assessment (Full ILA)

0A. Cover Sheet: INDIVIDUAL IDENTIFICATION

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

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1.d. City or town of Primary Emergency Contact?

1.e. State of Primary Emergency Contact?

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, would the client be able 

to get out of his/her home safely?

A - Yes

B - No

6. In the case of an emergency, would the client be able 

to summon help to his/her home?

A - Yes

B - No

7. Does the client require immediate assistance 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 communication barriers for which you need 

assistance?

A - Yes

B - No

3. If yes, type of assistance?

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4. Client's primary language.

E - English

L - American Sign 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. Home phone number of the client's agent with Power 

of Attorney.

2.a. Does the client have a Representative Payee?

A - Yes

B - No

2.b. Name of client'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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2a. What is client's race/ethnicity?

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 you admitted to a hospital for any reason in the 

last 30 days?

A - Yes

B - No

2. In the past year, how many 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 you eat fewer than 2 meals per day?

A - Yes (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 you eat fewer than two servings of dairy products 

(such as milk, yogurt, or cheese) every day?

A - Yes (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. Is the client participating in any of the following 

services 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. Does the client want to apply for any of the following 

services 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 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 social security income.

 $

1.a.2. Monthly social security 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 bank/institution where 

the client'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 account #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 

insurance 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 care needs (Regardless of the consequence of the 

decision)?

A - Yes

B - No

C - Information unavailable

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. What is the relationship of the primary unpaid 

caregiver to the client?

6. What is the phone 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 any of the following sanitation issues exist in your 

home?

A - No running water

B - Contaminated 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. Have you felt down, depressed, hopeless or helpless?

A - Yes

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. What is the client's ability to make decisions 

regarding tasks 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. Indicate which of the following conditions/diagnoses 

the client currently has.

A - ENDOCRINE-Diabetes

B - ENDOCRINE-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. Select all infections that apply to the client's 

condition based on the client's clinical record, consult 

staff, physician and accept client statements that seem to 

have clinical validity. Do not record infections that have 

been resolved.

A - Antibiotic resistant infection (e.g.,Methicillin 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. Medical treatments that the client received during 

the last 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. Specify the highest ulcer stage (1-4) for any pressure 

ulcers the client has (specify 0 if the client has no 

pressure ulcers).

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1.b. Specify the highest ulcer stage (1-4) for any stasis 

ulcers the client 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=LIMITED ASSIST: Non-wt bearing physical help 

3+times OR non-wt bearing help + extensive help 1-2 

times 3=EXTENSIVE ASSIST: Wt-bearing help or full 

caregiver assistance 3+ times

4=TOTAL DEPENDENCE: Full caregiver assistance every 

time 8= Activity did not occur 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. Select the item for the most support provided during 

the last 7 days, for Dressing

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

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. Select the item for the most support provided during 

the last 7 days, for Bathing.

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

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. Select the item for the most support provided during 

the last 7 days, for Personal Hygiene

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

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. PERSONAL HYGIENE: How many DAYS per WEEK 

does the client need PCA for ADL personal hygiene? 

(Must enter zero if no time needed)

3.D. Comment on the client's ability to perform personal 

hygiene

4.A. MOBILITY IN BED During the past 7 days, how would 

you 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 - 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

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 MOBILITY How many MINUTES per DAY 

were needed for assistance for bed mobility? (Must enter 

zero if no time needed)

4.C.2. BED MOBILITY How many DAYS per WEEK 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. TOILET 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. ADAPTIVE DEVICES: How many DAYS per WEEK 

does the client need PCA for ADL adaptive devices? (Must 

enter zero if no time needed)

6.D. Comment on adaptive devices.

7.A. TRANSFER: 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. MOBILITY: During the past 7 days, how would you 

rate the client'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. Indicate the highest level of phone use 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

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. Comment on the client's ability to prepare meals.

3.A. MEDICATIONS 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. Indicate the most support provided for money 

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

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. Comment on the client's ability to perform household 

maintenance chores.

6.A. LIGHT HOUSEKEEPING: During the last 7 days how 

would you rate the client's ability 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. Indicate the highest level of shopping 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

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. MOBILITY 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. MONEY MANAGEMENT: (only enter for ASP) How 

many MINUTES per WEEK were needed for assistance for 

MONEY MANAGEMENT. (must enter zero if no time is 

needed)

5.C.1. HOUSEHOLD MAINTENANCE: (only 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. TRANSPORTATION: (ENTER FOR asp ONLY) How 

many MINUTES per WEEK were needed for assistance for 

transportation? (Must enter zero if no time needed)

10.C.1. EQUIPMENT 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. ADAPTIVE 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)

Enter any comments regarding the client's ability to 

perform Mobility Outdoors.

6D. Functional Assessment: ADL/IADL Unmet Needs

Enter any additional comments regarding IADLs.

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ADL/IADL Comments- Identify unmet needs if any. 

Variance request must include

1. Description 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. Estimated/requested Incontinence needs:

Bowel 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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2. Calculated needs for HCBS Personal Care Worksheet

2.A. Calculated ADL/Meal Prep + Meds Management 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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3. Potential Issues Checklist

3.A. Health 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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Title : Date 

Title : Date 

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 Caregiver Evaluation 

Caregiver’s Name:

Initial Evaluation Date:

Re-evaluation Date:

Items: No Yes

Time Dependency Items: Do you Feel ~ 0 1

He/she needs my help to perform many daily task

He/she is dependent on you

You have to watch him/her constantly

You have to help him/her with many basic functions

You don’t have a minute’s break from his/her chores

Development Items: Do you Feel ~

That you want to escape from this situation

Your social life has suffered

Emotionally drained due to caring for him/her

Things would be different at this point in your life

Completely overwhelmed/lonely

A loss of privacy and/or personal time

You don’t have enough knowledge or experience to give care as well as you would like

Physical Health Items: Do you Feel ~

Tired – not getting enough sleep

Your health has suffered (headaches, stomach problems, etc.)

You have trouble keeping your mind on what you were doing

You have difficulty making decisions

You have had crying spells or deep sadness

You have frequent pain (back pain, etc.)

Have you lost or gained 10 pounds in the past 6 months

Social Relationships Items: Do you Feel ~

You don’t get along with other family members as well as you used to

My caregiving efforts aren’t appreciated by others in my family

You’ve had problems with your marriage (or other significant relationship)

You don’t get along as well as you used to with others

Emotional Health Items: Do you Feel ~

Embarrassed over his/her behavior

Uncomfortable when you have friends over (social relationships)

Resentment towards him/her

Upset that the person I’m caring for has changed so much from his/her former self

Family members aren’t helping you with Caregiving responsibilities?

Strained between work and family responsibilities

20-30 Plus Caregiver needs relief / 10-19 Caregiver needs assistance / 0-9 Caregiver needs to be contacted annually.

Total Score

Access Care Coordinator’s Signature Date Caregiver’s Signature Date 

I give permission for sharing of information 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. 

October 2012

Wyoming Caregiver Evaluation 139