HSS26066-CARERESCTR_AttA.pdf
PDF 238 KB Posted
- Attached to
- Caregiver Resource Centers
- Solicitation number
- HSS26066-CARERESCTR
- Issued by
- Delaware
About this file
This is an Intake Assessment Form (CF-044) used by the State of Delaware Division of Services for Aging and Adults with Physical Disabilities for the Caregiver Resource Centers program. The form is designed to collect comprehensive caregiver information required for federal data reporting purposes. The assessment captures demographic details including the caregiver's name, preferred pronouns, contact information (telephone and email), date of birth or applicable age range, and residential address with county designation (New Castle, Kent, or Sussex County).
The form serves as the initial documentation tool for CRC Coordinators to systematically gather and record caregiver intake data. All information fields are identified as mandatory for compliance with federal reporting requirements. The document establishes a standardized format for consistent data collection across the Caregiver Resource Centers program, enabling the state to maintain accurate records and fulfill federal data reporting obligations related to the services provided to caregivers and individuals with physical disabilities.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| HSS26066-CARERESCTR_appE.xlsx | XLSX spreadsheet | |
| HSS26066-CARERESCTR_AppD.pdf | ||
| HSS26066-CARERESCTR_AttB.pdf | ||
| HSS26066-CARERESCTR_appC.xlsx | XLSX spreadsheet |
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Text version
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
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
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File details come from the government source that posted it. Updated .