Mathematica Policy Research, Inc.
March 29, 1982
This instrument was developed for the National Long-Term Care Channeling Demonstration. This project was conducted by Mathematica Policy Research, Inc. under contract #HHS-100-80-0157 and Temple University under contract #HHS-100-80-0133 for the Department of Health and Human Services (HHS) Office of Social Services Policy (now Office of Disability, Aging and Long-Term Care Policy), as well as additional funding from the HHS Health Care Financing Administration (now Centers for Medicare and Medicaid Services) and HHS Administration on Aging. For additional information about this subject, you can visit the DALTCP home page at http://aspe.hhs.gov/_/office_specific/daltcp.cfm or contact the office at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, SW, Washington, DC 20201. The e-mail address is: webmaster.DALTCP@hhs.gov. The DALTCP Project Officer was Robert Clark.
| NOTE: This is a recreation of this form. See the PDF version for a scanned version of the actual form. |
MPRI 736
OMB # 0990-0080
Expires 9/84
CLIENT TRACKING FORM
MPR APPLICANT/CLIENT ID# [_____ _____] [_____ _____ _____ _____ _____] [_____]
3/29/82
| CLIENT/APPLICANT INFORMATION | WORKER IDENTIFICATION | ||
| NAME: | _________________________ | SCREENER: | [_____]_____]_____]_____] |
| PERMANENT ADDRESS: | _________________________ | ASSESSOR: | [_____]_____]_____]_____] |
| _________________________ | 1ST CASE MANAGER: | [_____]_____]_____]_____] | |
| TELEPHONE: | _________________________ | 2ND CASE MANAGER: | [_____]_____]_____]_____] |
| BIRTHDATE: | [_____ _____]_____ _____]_____ _____] [Mo/Day/Yr] | EFFECTIVE DATE: | [_____]_____]_____]_____]_____]_____] |
| PROXY NAME: | _________________________ | 1ST REASSESSOR: | [_____]_____]_____]_____] |
| PROXY TELEPHONE: | _________________________ | 2ND REASSESSOR: | [_____]_____]_____]_____] |
| REFERRAL SOURCE: | _________________________ | EFFECTIVE DATE: | [_____]_____]_____]_____]_____]_____] |
| ACTIONS | DATE [Month/Day/Year] | OUTCOMES * [Circle One] | REFERRED TO * | DATE REFERRED [Mo/Day/Yr] |
| I. SCREENING | SEND COPY OF TF TO MPR FOR BOLD-FACED OUTCOMES | # Reason Inappropriate at Screen [Circle One] 1. Too Service Dependent 2. Insufficient Disability 3. Insufficient unmet need 4. Age under 65 5. Outside catchment area 6. Not Medicare eligible 7. Other | ||
| * A. REFERRED TO UNIT | [___ ___]___ ___]___ ___] | |||
| * B. SCREENING INTERVIEW | [___ ___]___ ___]___ ___] | 1. INAPPROPRIATE (Circle Reason #) 2. REFUSED 3. UNABLE TO COMPLETE (OTHER) | _________________________ _________________________[___]___] REFERRED TO | [___]___]___]___]___]___] |
| [___ ___]___ ___]___ ___] | 4. APPROPRIATE | |||
| C. SUPERVISORY REVIEW | [___ ___]___ ___]___ ___] | |||
| * D. RANDOMIZATION DECISION RECEIVED | [___ ___]___ ___]___ ___] | 1. CONTROL | _________________________ _________________________[___]___] REFERRED TO | [___]___]___]___]___]___] |
| [___ ___]___ ___]___ ___] | 2. CLIENT | |||
| E. SCREEN SENT TO MPR | [___ ___]___ ___]___ ___] | COMPLETE SECTION V IF CLIENT FROPS OUT AFTER RANDOMIZATION | ||
| F. CONTACT ASSESSMENT UNIT | [___ ___]___ ___]___ ___] | |||
| G. SCREEN & TF TRANSFERRED TO ASSESSMENT | [___ ___]___ ___]___ ___] | |||
| ACTIONS | DATE [Month/Day/Year] | OUTCOMES * [Circle One] | REFERRED TO * | DATE REFERRED [Mo/Day/Yr] |
| II. BASELINE ASSESSMENT | SEND COPIES OF TF TO MPR FOR BOLD-FACED OUTCOMES | |||
| * A. ASSIGNED TO WORKER | [___ ___]___ ___]___ ___] | |||
| * B. OBTAIN INFORMED CONSENT | [___ ___]___ ___]___ ___] | 1. REFUSED + 2. UNABLE TO COMPLETE (OTHER) + | _________________________ _________________________[___]___] REFERRED TO | [___]___]___]___]___]___] |
| [___ ___]___ ___]___ ___] | 3. COMPLETE | |||
| * C. BASELINE ASSESSMENT | [___ ___]___ ___]___ ___] | 1. INAPPROPRIATE + 2. REFUSED + 3. UNABLE TO COMPLETE (OTHER) + | _________________________ _________________________[___]___] REFERRED TO | [___]___]___]___]___]___] |
| [___ ___]___ ___]___ ___] | 4. APPROPRIATE | |||
| D. ASSESSEMENT SUMMARY FORM COMPLETED | [___ ___]___ ___]___ ___] | + Complete Section V.A. | ||
| E. SUPERVISORY APPROVAL | [___ ___]___ ___]___ ___] | |||
| ACTIONS | DATE [Month/Day/Year] | OUTCOMES * [Circle One] | REFERRED TO * | DATE REFERRED [Mo/Day/Yr] |
| III. CARE PLANNING | ||||
| A. ASSIGNED FOR CARE PLAN PREPARATION | [___ ___]___ ___]___ ___] | |||
| * B. CARE PLAN COMPLETED [INCLUDING SUPERVISORY APPROVAL] | [___ ___]___ ___]___ ___] | |||
| * C. CARE PLAN APPROVED BY CLIENT/FAMILY | [___ ___]___ ___]___ ___] | 1. REFUSED + | _________________________ _________________________[___]___] REFERRED TO | [___]___]___]___]___]___] |
| [___ ___]___ ___]___ ___] | 2. ACCEPTED [ACTIVE] | |||
| * D. FIRST SERVICE INITIATED | [___ ___]___ ___]___ ___] | |||
| E. COPY OF TF SENT TO MPR | [___ ___]___ ___]___ ___] |
| IV. ARRANGING/MONITORING/REASSESSMENT | ||||
| SERVICES ADDED OR DELETED | ||||
| FIRST REASSESSMENT SCHEDULED FOR: | _________________________ | REASSESSMENTS COMPLETED: | DATE | COMMENTS |
| NEXT SCHEDULED: | _________________________ | _________________________ | _________________________ | _________________________ |
| _________________________ | _________________________ | _________________________ | _________________________ | |
| _________________________ | _________________________ | _________________________ | _________________________ | |
| _________________________ | _________________________ | _________________________ | _________________________ | |