2-HSS-26-066 - CRC-AttA.docx
DOCX document 70 KB Posted
- Attached to
- CAREGIVER RESOURCE CENTERS
- Solicitation number
- HSS-26-066
- Issued by
- Delaware
About this file
This is an Intake Assessment Form (CF-044) developed by the State of Delaware Division of Services for Aging and Adults with Physical Disabilities in support of the Caregiver Resource Centers (CRC) contract opportunity. The form is designed to collect standardized caregiver information required for federal data reporting purposes. The assessment captures essential demographic and contact information for caregivers, including first and last names, preferred pronouns, complete address details organized by Delaware county (New Castle, Kent, or Sussex), telephone numbers, email address, and date of birth with an alternative age range option if date of birth cannot be obtained. The form designates fields for the CRC Coordinator name and assessment date to ensure proper documentation and tracking of intake activities.
The Caregiver Resource Centers program aims to serve unpaid caregivers throughout Delaware by providing person-centered information, assistance with referrals, community outreach, education, and access to services and assistive technologies. The intake assessment form serves as the foundational documentation tool for CRCs operating as community-based access points within the caregiver action network, enabling data collection necessary for federal compliance and service tracking. The form's structure ensures consistent capture of caregiver demographic information across all CRC locations, supporting the program's goal of empowering unpaid caregivers to navigate their caregiving journeys effectively.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| 7-HSS-26-066 - AppE-Budget Wkbk-CRC.xlsx | XLSX spreadsheet | |
| 5-HSS-26-066 - AppC-Vendor Frms.xlsx | XLSX spreadsheet | |
| 3-HSS-26-066 - CRC-AttB.docx | DOCX document | |
| 4-HSS-26-066 - CRC-AttC-OAAPS Mthly Rpt.xlsx | XLSX spreadsheet | |
| 1-HSS-26-066 - CRC - Final.docx | DOCX document | |
| 6-HSS-26-066 - AppD-Templates-PSA, BAA DTI TCs.docx | DOCX document |
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Text version
STATE OF DELAWARE
Enter Agency Name
STATE OF DELAWARE
DIVISION OF SERVICES FOR AGING AND ADULTS WITH PHYISICAL DISABILITIES
ATTACHMENT A
Intake Assessment Form CF-044
Date of Assessment:
CRC Coordinator Name:
Please fill in all information, as it is required for federal data reporting.
CAREGIVER INFORMATION
| First Name: |
| Last Name: |
Preferred Name:
| Preferred Pronouns: |
| ☐She/Her |
☐He/Him ☐They/Them ☐Other:
| Address: |
| Apt #: |
| County: ☐ NCC ☐ Kent ☐ Sussex |
Address 2 (Apt. Complex Name or Development Name):
| City: |
| State: |
| Zip: |
| Telephone 1: |
| Telephone 2: |
Email Address:
| Date of Birth (DOB): |
| ☐ Not Reported |
If DOB is unable to be collected, please check appropriate age range: ☐ <50 ☐ 50-59 ☐ 60-64 ☐ 65-74 ☐ 75-84 ☐ 85+
| Ethnicity: |
| ☐ Hispanic or Latino ☐ NOT Hispanic or Latino |
| Race: |
| ☐ White – Non-Hispanic |
☐ White – Hispanic
☐ American Indian/Alaska Native
☐ Asian
☐ Black or African American
☐ Native Hawaiian or Other Pacific Islander
☐ Other Race
| Reporting 2 or More Races: |
| ☐ YES |
| Race Data Missing: |
| ☐ YES |
Are you the PRINCIPAL CAREGIVER? ☐Yes ☐No
Does the care recipient live with you? ☐ Yes ☐ No
Care Recipients Name:
Relationship to Care Recipient:
☐ Husband ☐ Wife ☐ Son/Son-in-Law ☐ Daughter/Daughter-in-Law ☐ Other Relative ☐ Non-Relative ☐ Relationship Not Reported
Does the Care Recipient have Alzheimer’s Disease or Related Dementia Diagnosis? ☐ Yes ☐ No
Do you also care for children under 18 living at home? ☐ Yes ☐ No
| Employment Status |
| ☐ Employed Full-Time |
| ☐ Employed Part-Time |
| ☐ Not Employed |
| Does caregiving impact your employment status? |
| ☐ Yes |
| ☐ No |
| ☐ Sometimes |
How does caregiving impact your employment status?
If you are currently unemployed or underemployed, do you want to work?
☐ Yes ☐ No ☐ Full-Time ☐ Part-Time
| On average, how many weekly hours of care do you provide? |
| ☐ Less than 10 |
| ☐ 11 -20 |
| ☐ 21 - 30 |
| ☐ 30+ |
| Self-Reported Caregiver Burden Scale |
| ☐1 (Very Little Burden/Stress) ☐2 ☐3 ☐4 ☐5 ☐6 ☐7 ☐8 ☐9 ☐10 (High Burden/Stress) |
What services, supports or needs is the caregiver reporting/requesting?
| Identify supportive services that are recommended to this Caregiver based on their needs: |
| ☐ Caregiver Skills Training |
☐ Adult Day Program ☐ In-Home Respite ☐ ERS Services ☐ Counseling ☐ Legal Assistance ☐ Home Modification ☐ Assistive Technology ☐ Support Group ☐ Dementia Education/Support ☐ Transportation ☐ Other:
Caregiver was given the following information/publications:
| ☐ ADRC Brochure |
| ☐ CRC Flyer/Brochure |
| ☐ DSAAPD Guide to Services |
☐ Other:
CARE RECIPIENT INFORMATION
| First Name: |
| Last Name: |
Preferred Name:
| Preferred Pronouns: |
| ☐She/Her |
☐He/Him ☐They/Them ☐Other:
Check if same address as Caregiver ☐
| Address: |
| Apt #: |
| County: ☐ NCC ☐ Kent ☐ Sussex |
Address 2 (Apt. Complex Name or Development Name):
| City: |
| State: |
| Zip: |
Telephone 1:
Email Address:
| Date of Birth (DOB): |
| ☐ Not Reported |
If DOB is unable to be collected, please check appropriate age range: ☐ <50 ☐ 50-54 ☐ 55-59 ☐ 60-74 ☐ 75-84 ☐ 85+
| Ethnicity: |
| ☐ Hispanic or Latino ☐ NOT Hispanic or Latino |
| Race: |
| ☐ White – Non-Hispanic |
☐ White – Hispanic
☐ American Indian/Alaska Native
☐ Asian
☐ Black or African American
☐ Native Hawaiian or Other Pacific Islander
☐ Other Race
| Reporting 2 or More Races: |
| ☐ YES |
| Race Data Missing: |
| ☐ YES |
Does the Care Recipient have a PRINCIPAL CAREGIVER? ☐Yes ☐No
Does the care recipient live alone? ☐ Yes ☐ No If No, how many in household?
Caregiver’s Name:
| How many of the following 6 ADL’s is the care recipient UNABLE to perform without personal assistance, standby assistance, supervision, or cues? |
| ☐Dressing |
☐Bathing ☐Toileting ☐Transferring in/out of bed/chair ☐Eating ☐ Walking Total Care Recipient ADL’s
☐0 ☐1 ☐2 ☐3+
| How many of the following 8 IADL’s is the care recipient UNABLE to perform without personal assistance, standby assistance, supervision, or cues? |
| ☐Preparing Meals |
☐Medication Management ☐Money Management ☐Using the Telephone ☐Doing Heavy Housework ☐Doing Light Housework ☐Access Transportation ☐with Assistance ☐Personal Shopping Total Care Recipient IADL’s
☐0 ☐1 ☐2 ☐3+
| Services recommended to/for the care recipient are: |
| ☐ ADRC Referral |
☐Personal Care ☐ Adult Day Program ☐ ERS Services ☐ Meals ☐ Financial Assistance ☐ Legal Assistance ☐ Home Modification ☐ Assistive Technology ☐ Support Group ☐ Caregiver Resource Center ☐ Transportation ☐ Other:
Notes: Click here to enter text.
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