Screening Identification Sheet

03/15/1982

 

 


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.

 

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 OTHER

NAME: _________________________
RELATIONSHIP: _________________________
STREET ADDRESS: _________________________  APT/FLOOR: _________________________
CITY: _________________________  STATE: _____  ZIP: _____
TELEPHONE: |_____|_____|_____| - |_____|_____|_____| - |_____|_____|______|_____|

ID10. IDENTITY OF SIGNIFICANT OTHER

|_____| SAME AS LEGAL GUARDIAN
|_____| SAME AS REFERRAL SOURCE

NAME: _________________________
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.

_________________________
SCREENER SIGNATURE


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]

 

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