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. |
NATIONAL LONG TERM CARE DEMONSTRATION
SCREENING IDENTIFICATION SHEET
MPR #740, March 15, 1982
| APPLICANT ID: |_____|_____| - |_____|_____|_____|______|_____| - |_____| |
* ID1. APPLICANT NAME
FIRST _________________________ MI _____ LAST _________________________
* ID2. PERMANENT STREET ADDRESS
INSTITUTION/c/o _________________________
STREET _________________________ APT/FLOOR _________________________
CITY _________________________ STATE _____ ZIP CODE _____
* ID3. PERMANENT TELEPHONE: |_____|_____|_____| - |_____|_____|_____| - |_____|_____|______|_____|
NO TELEPHONE . . . . . -4
NO INFORMATION . . . . . -1
ID4. CURRENT STREET ADDRES, IF DIFFERENT FROM ABOVE
INSTITUTION/c/o _________________________
STREET _________________________ APT/FLOOR _________________________
CITY _________________________ STATE _____ ZIP CODE _____
* ID6. MEDICARE NUMBER: |_____|_____|_____| - |_____|_____| - |_____|_____|______|_____| - |_____| - |_____| (ID7)
* ID6a. RAILROAD RETIREMENT MEDICARE: _________________________ (ID7)
NOT COVERED BY MEDICARE . . . . . -4
NO INFORMATION . . . . . -1
* ID6b. SOCIAL SECURITY NUMBER (IF NO MEDICARE NUMBER IN ID6 OR ID6a: |_____|_____|_____| - |_____|_____| - |_____|_____|______|_____| (ID7)
APPLICANT HAS NO SOCIAL SECURITY NUMBER . . . . . -4
NO INFORMATION . . . . . -1
* ID6c. RAILROAD RETIREMENT NUMBER (IF NO RR MEDICARE NUMBERIN ID6a): _________________________
NOT RAILROAD RETIREMENT . . . . . -4
NO INFORMATION . . . . . -1
* ID7. MEDICAID NUMBER: _________________________
NOT MEDICAID . . . . . -4
NO INFORMATION . . . . . -1
ID8. IDENTITY OF REFERRAL SOURCE
NAME: _________________________
RELATIONSHIP/AGENCY: _________________________ (CODE IN A11)
STREET ADDRESS: _________________________ APT/FLOOR: _________________________
CITY: _________________________ STATE: _____ ZIP: _____
TELEPHONE: |_____|_____|_____| - |_____|_____|_____| - |_____|_____|______|_____|
| GO TO A10 ON PAGE 2 OF SCREEN |
ID9. IDENTITY OF LEGAL GUARDIAN
|_____| SAME AS REFERRAL SOURCE
|_____| SAME AS SIGNIFICANT OTHERNAME: _________________________
RELATIONSHIP: _________________________
STREET ADDRESS: _________________________ APT/FLOOR: _________________________
CITY: _________________________ STATE: _____ ZIP: _____
TELEPHONE: |_____|_____|_____| - |_____|_____|_____| - |_____|_____|______|_____|
ID10. IDENTITY OF SIGNIFICANT OTHER
|_____| SAME AS LEGAL GUARDIAN
|_____| SAME AS REFERRAL SOURCENAME: _________________________
RELATIONSHIP: _________________________
STREET ADDRESS: _________________________ APT/FLOOR: _________________________
CITY: _________________________ STATE: _____ ZIP: _____
TELEPHONE: |_____|_____|_____| - |_____|_____|_____| - |_____|_____|______|_____|
ID11. FULL NAMES OF OTHERS AGE 65 OR OLDER IN HOUSEHOLD (FROM C2 OF SCREEN).
FIRST MIDDLE INITIAL LAST
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
COMPLETE ID12-ID15 AFTER ASCERTAINING INTEREST
*ID12. NUMBER OF CONTACTS TO REACH FINAL STATUS: |_____|_____|
* ID13. DATE OF FINAL STATUS: MONTH |_____|_____| DAY |_____|_____| YEAR |_____|_____|
* ID14. AFTER COMPLETION OF SCREEN, IS APPLICANT INTERESTED IN PARTICIPATING?
YES . . . . . 01
NO . . . . . 02 (END)
INCOMPLETE . . . . . -4 (END)
ID15. SCREENER CERTIFICATION OF APPLICANT INTEREST
| I certify that I have contacted the applicant (or a significant other), explained the program to him/her, and that the applicant is interested in participating. _________________________ |
NATIONAL LONG-TERM CARE CHANNELING DEMONSTRATION REPORTS AVAILABLE
A Guide to Memorandum of Understanding Negotiation and Development
HTML http://aspe.hhs.gov/daltcp/reports/mouguide.htm
PDF http://aspe.hhs.gov/daltcp/reports/mouguide.pdf
An Analysis of Site-Specific Results
Executive Summary http://aspe.hhs.gov/daltcp/reports/sitees.htm
HTML http://aspe.hhs.gov/daltcp/reports/1986/sitees.htm
PDF http://aspe.hhs.gov/daltcp/reports/1986/sitees.pdf
Analysis of Channeling Project Costs
Executive Summary http://aspe.hhs.gov/daltcp/reports/projctes.htm
HTML http://aspe.hhs.gov/daltcp/reports/1986/projctes.htm
PDF http://aspe.hhs.gov/daltcp/reports/1986/projctes.pdf
Analysis of the Benefits and Costs of Channeling
Executive Summary http://aspe.hhs.gov/daltcp/reports/1986/costes.htm
HTML http://aspe.hhs.gov/daltcp/reports/1986/cost.htm
PDF http://aspe.hhs.gov/daltcp/reports/1986/cost.pdf
Applicant Screen Set
HTML http://aspe.hhs.gov/daltcp/reports/1982/appscset.htm
PDF http://aspe.hhs.gov/daltcp/reports/1982/appscset.pdf
Assessment and Care Planning for the Frail Elderly: A Problem Specific Approach
HTML http://aspe.hhs.gov/daltcp/reports/1986/asmtcare.htm
PDF http://aspe.hhs.gov/daltcp/reports/1986/asmtcare.pdf
Assessment Training for Case Managers: A Trainer's Guide
HTML http://aspe.hhs.gov/daltcp/reports/1985/asmttran.htm
PDF http://aspe.hhs.gov/daltcp/reports/1985/asmttran.pdf
Case Management Forms Set
HTML http://aspe.hhs.gov/daltcp/reports/1985/cmforms.htm
PDF http://aspe.hhs.gov/daltcp/reports/1985/cmforms.pdf
Case Management Training for Case Managers: A Trainer's Guide
HTML http://aspe.hhs.gov/daltcp/reports/1985/cmtrain.htm
PDF http://aspe.hhs.gov/daltcp/reports/1985/cmtrain.pdf
Channeling Effects for an Early Sample at 6-Month Follow-up
Executive Summary http://aspe.hhs.gov/daltcp/reports/6monthes.htm
HTML http://aspe.hhs.gov/daltcp/reports/1985/6monthes.htm
PDF http://aspe.hhs.gov/daltcp/reports/1985/6monthes.pdf
Channeling Effects on Formal Community-Based Services and Housing
Executive Summary http://aspe.hhs.gov/daltcp/reports/commtyes.htm
HTML http://aspe.hhs.gov/daltcp/reports/1986/commty.htm
PDF http://aspe.hhs.gov/daltcp/reports/1986/commty.pdf
Channeling Effects on Hospital, Nursing Home and Other Medical Services
Executive Summary http://aspe.hhs.gov/daltcp/reports/hospites.htm
HTML http://aspe.hhs.gov/daltcp/reports/1986/hospites.htm
PDF http://aspe.hhs.gov/daltcp/reports/1986/hospites.pdf
Channeling Effects on Informal Care
Executive Summary http://aspe.hhs.gov/daltcp/reports/informes.htm
HTML http://aspe.hhs.gov/daltcp/reports/1986/informes.htm
PDF http://aspe.hhs.gov/daltcp/reports/1986/informes.pdf
Channeling Effects on the Quality of Clients' Lives
Executive Summary http://aspe.hhs.gov/daltcp/reports/qualtyes.htm
HTML http://aspe.hhs.gov/daltcp/reports/1986/qualtyes.htm
PDF http://aspe.hhs.gov/daltcp/reports/1986/qualtyes.pdf
Clinical Baseline Assessment Instrument Set
HTML http://aspe.hhs.gov/daltcp/reports/cbainstr.htm
PDF http://aspe.hhs.gov/daltcp/reports/cbainstr.pdf
Community Services and Long-Term Care: Issues of Negligence and Liability
HTML http://aspe.hhs.gov/daltcp/reports/negliab.htm
PDF http://aspe.hhs.gov/daltcp/reports/negliab.pdf
Differential Impacts Among Subgroups of Channeling Enrollees
Executive Summary http://aspe.hhs.gov/daltcp/reports/enrolles.htm
HTML http://aspe.hhs.gov/daltcp/reports/1986/enrolles.htm
PDF http://aspe.hhs.gov/daltcp/reports/1986/enrolles.pdf
Differential Impacts Among Subgroups of Channeling Enrollees Six Months After Randomization
Executive Summary http://aspe.hhs.gov/daltcp/reports/difimpes.htm
HTML http://aspe.hhs.gov/daltcp/reports/1984/difimpes.htm
PDF http://aspe.hhs.gov/daltcp/reports/1984/difimpes.pdf
Examination of the Equivalence of Treatment and Control Groups and the Comparability of Baseline Data
Executive Summary http://aspe.hhs.gov/daltcp/reports/baslines.htm
HTML http://aspe.hhs.gov/daltcp/reports/1984/baslines.htm
PDF http://aspe.hhs.gov/daltcp/reports/1984/baslines.pdf
Final Report on the Effects of Sample Attrition on Estimates of Channeling's Impacts
Executive Summary http://aspe.hhs.gov/daltcp/reports/1986/atritnes.htm
HTML http://aspe.hhs.gov/daltcp/reports/1986/atritn.htm
PDF http://aspe.hhs.gov/daltcp/reports/1986/atritn.pdf
Informal Care to the Impaired Elderly: Report of the National Long-Term Care Demonstration Survey of Informal Caregivers
Executive Summary http://aspe.hhs.gov/daltcp/reports/impaires.htm
HTML http://aspe.hhs.gov/daltcp/reports/1984/impaires.htm
PDF http://aspe.hhs.gov/daltcp/reports/1984/impaires.pdf
Informal Services and Supports
HTML http://aspe.hhs.gov/daltcp/reports/1985/infserv.htm
PDF http://aspe.hhs.gov/daltcp/reports/1985/infserv.pdf
Initial Research Design of the National Long-Term Care Demonstration
HTML http://aspe.hhs.gov/daltcp/reports/designes.htm
PDF http://aspe.hhs.gov/daltcp/reports/designes.pdf
Issues in Developing the Client Assessment Instrument for the National Long-Term Care Channeling Demonstration
HTML http://aspe.hhs.gov/daltcp/reports/1981/instrues.htm
PDF http://aspe.hhs.gov/daltcp/reports/1981/instrues.pdf
Methodological Issues in the Evaluation of the National Long-Term Care Demonstration
Executive Summary http://aspe.hhs.gov/daltcp/reports/methodes.htm
HTML http://aspe.hhs.gov/daltcp/reports/1986/methodes.htm
PDF http://aspe.hhs.gov/daltcp/reports/1986/methodes.pdf
National Long-Term Care Channeling Demonstration: Summary of Demonstration and Reports
HTML http://aspe.hhs.gov/daltcp/reports/1991/chansum.htm
PDF http://aspe.hhs.gov/daltcp/reports/1991/chansum.pdf
Screening Training for Screeners: A Trainer's Guide
HTML http://aspe.hhs.gov/daltcp/reports/1985/scretrai.htm
PDF http://aspe.hhs.gov/daltcp/reports/1985/scretrai.pdf
Survey Data Collection Design and Procedures
Executive Summary http://aspe.hhs.gov/daltcp/reports/sydataes.htm
HTML http://aspe.hhs.gov/daltcp/reports/1986/sydataes.htm
PDF http://aspe.hhs.gov/daltcp/reports/1986/sydataes.pdf
Tables Comparing Channeling to Other Community Care Demonstrations
HTML http://aspe.hhs.gov/daltcp/reports/1986/tablees.htm
PDF http://aspe.hhs.gov/daltcp/reports/1986/tablees.pdf
The Channeling Case Management Manual
HTML http://aspe.hhs.gov/daltcp/reports/1986/cmmanual.htm
PDF http://aspe.hhs.gov/daltcp/reports/1986/cmmanual.pdf
The Channeling Financial Control System
HTML http://aspe.hhs.gov/daltcp/reports/1985/chanfcs.htm
PDF http://aspe.hhs.gov/daltcp/reports/1985/chanfcs.pdf
The Comparability of Treatment and Control Groups at Randomization
HTML http://aspe.hhs.gov/daltcp/reports/compares.htm
PDF http://aspe.hhs.gov/daltcp/reports/compares.pdf
The Effects of Case Management and Community Services on the Impaired Elderly
Executive Summary http://aspe.hhs.gov/daltcp/reports/casmanes.htm
HTML http://aspe.hhs.gov/daltcp/reports/1986/casmanes.htm
PDF http://aspe.hhs.gov/daltcp/reports/1986/casmanes.pdf
The Effects of Sample Attrition on Estimates of Channeling's Impacts for an Early Sample
HTML http://aspe.hhs.gov/daltcp/reports/1984/earlyes.htm
PDF http://aspe.hhs.gov/daltcp/reports/1984/earlyes.pdf
The Evaluation of the National Long-Term Care Demonstration: Final Report
Executive Summary http://aspe.hhs.gov/daltcp/reports/chanes.htm
HTML http://aspe.hhs.gov/daltcp/reports/1986/chanfr.htm
PDF http://aspe.hhs.gov/daltcp/reports/1986/chanfr.pdf
The Evaluation of the National Long-Term Care Demonstration
Executive Summary http://aspe.hhs.gov/daltcp/reports/hsres.htm
HTML http://aspe.hhs.gov/daltcp/reports/1988/hsre.htm
PDF http://aspe.hhs.gov/daltcp/reports/1988/hsre.pdf
The Planning and Implementation of Channeling: Early Experiences of the National Long-Term Care Demonstration
Executive Summary http://aspe.hhs.gov/daltcp/reports/implees.htm
HTML http://aspe.hhs.gov/daltcp/reports/1983/imple.htm
PDF http://aspe.hhs.gov/daltcp/reports/1983/imple.pdf
The Planning and Operational Experience of the Channeling Projects
Executive Summary http://aspe.hhs.gov/daltcp/reports/proceses.htm
HTML http://aspe.hhs.gov/daltcp/reports/1986/proceses.htm
PDF http://aspe.hhs.gov/daltcp/reports/1986/proceses.pdf
INSTRUMENTS AVAILABLE
Applicant Screen
HTML http://aspe.hhs.gov/daltcp/instruments/1981/AppSc.htm
PDF http://aspe.hhs.gov/daltcp/instruments/1981/AppSc.pdf
Client Contact Log
HTML http://aspe.hhs.gov/daltcp/instruments/ClConLog.htm
PDF http://aspe.hhs.gov/daltcp/instruments/ClConLog.pdf
Client Tracking/Status Change Form
HTML http://aspe.hhs.gov/daltcp/instruments/ClTracFm.htm
PDF http://aspe.hhs.gov/daltcp/instruments/ClTracFm.pdf
Clinical Assessment and Research Baseline Instrument: Community Version
HTML http://aspe.hhs.gov/daltcp/instruments/carbicv.htm
PDF http://aspe.hhs.gov/daltcp/instruments/carbicv.pdf
Clinical Baseline Assessment Instrument: Community Version
HTML http://aspe.hhs.gov/daltcp/instruments/cbaicv.htm
PDF http://aspe.hhs.gov/daltcp/instruments/cbaicv.pdf
Clinical Baseline Assessment Instrument: Institutional Version
HTML http://aspe.hhs.gov/daltcp/instruments/cbaiiv.htm
PDF http://aspe.hhs.gov/daltcp/instruments/cbaiiv.pdf
Eighteen Month Followup Instrument
HTML http://aspe.hhs.gov/daltcp/instruments/18mfi.htm
PDF http://aspe.hhs.gov/daltcp/instruments/18mfi.pdf
Followup Instrument
HTML http://aspe.hhs.gov/daltcp/instruments/FolInst.htm
PDF http://aspe.hhs.gov/daltcp/instruments/FolInst.pdf
Informal Caregiver Followup Instrument
HTML http://aspe.hhs.gov/daltcp/instruments/ICFolIns.htm
PDF http://aspe.hhs.gov/daltcp/instruments/ICFolIns.pdf
Informal Caregiver Survey Baseline
HTML http://aspe.hhs.gov/daltcp/instruments/ICSurvey.htm
PDF http://aspe.hhs.gov/daltcp/instruments/ICSurvey.pdf
Screening Identification Sheet
HTML http://aspe.hhs.gov/daltcp/instruments/1982/ScrIDSh.htm
PDF http://aspe.hhs.gov/daltcp/instruments/1982/ScrIDSh.pdf
Time Sheet
HTML http://aspe.hhs.gov/daltcp/instruments/TimeSh.htm
PDF http://aspe.hhs.gov/daltcp/instruments/TimeSh.pdf
Twelve Month Followup Instrument
HTML http://aspe.hhs.gov/daltcp/instruments/12mfi.htm
PDF http://aspe.hhs.gov/daltcp/instruments/12mfi.pdf
To obtain a printed copy of this report, send the full report title and your mailing information to:
U.S. Department of Health and Human Services
Office of Disability, Aging and Long-Term Care Policy
Room 424E, H.H. Humphrey Building
200 Independence Avenue, S.W.
Washington, D.C. 20201
FAX: 202-401-7733
Email: webmaster.DALTCP@hhs.gov
RETURN TO:
Office of Disability, Aging and Long-Term Care Policy (DALTCP) Home [http://aspe.hhs.gov/_/office_specific/daltcp.cfm]
Assistant Secretary for Planning and Evaluation (ASPE) Home [http://aspe.hhs.gov]
U.S. Department of Health and Human Services Home [http://www.hhs.gov]