DOEA 701B Form PDF Details

In the realm of elder care and support within the state of Florida, the DOEA 701B Comprehensive Assessment Form emerges as a critical document, articulated by the Florida Department of Elder Affairs. At the heart of this form lies a meticulous gathering of demographic, health, sensory, communication, and daily living activity data, aimed at crafting a nuanced understanding of the elderly's needs. Embarking with sections that traverse through basic identification including social security and Medicaid numbers, it progresses to encapsulate details about the individual's living situation, caregiver dynamics, and their environment. A notable emphasis is placed on assessing the individual's physical health, cognitive capabilities including memory function, as well as sensory and communication abilities, to illuminate any assistance or devices that may be requisite. Moreover, the form inquires into activities of daily living (ADLs), gauging the level of dependence in tasks such as bathing, dressing, and mobility. This thorough evaluation not only underscores the initial, annual, or transitional situations that necessitate the assessment but also carves pathways for tailored care plans, ensuring the elderly receive apt support and resources indispensable for maintaining their dignity and quality of life.

QuestionAnswer
Form NameDOEA 701B Form
Form Length19 pages
Fillable?Yes
Fillable fields1316
Avg. time to fill out38 min 17 sec
Other names701b, florida 701b training, 701b certification, 701b assessment

Form Preview Example

 

 

Florida Department of Elder Affairs

 

 

701B Comprehensive Assessment

 

 

Rule: 58-A-1.010, F.A.C.

 

 

 

 

 

 

Provider ID:

 

 

Provider

 

Assessor/CM ID:

 

 

Assessor/Case

 

 

 

 

 

 

 

Manager (CM) Name:

 

 

Signature:

 

 

A. DEMOGRAPHIC SECTION

 

 

 

 

1.ASSESSOR/CM: What is the purpose of this assessment?

 

 

Initial Annual Health Living situation

Caregiver Environment

Income

 

 

2.

Social Security number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

Name: a. First:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b. Middle initial:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c. Last:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

Medicaid number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5.

Phone number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6.

Date of birth (mm/dd/yyyy):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7.

Sex:

 

 

Male

 

Female

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8.

Race (Mark all that apply):

 

 

White

 

Black/African American

 

Asian

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

American Indian/Alaska Native

 

Native Hawaiian/Pacific Islander

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

9.

Ethnicity:

 

 

Hispanic/Latino

 

Other

 

 

 

 

 

 

 

 

 

10.

Primary language:

 

 

English

 

Spanish

 

 

Other:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11.

Does client have limited ability reading, writing, speaking, or understanding English? No

 

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12.

Marital status:

 

 

Married

 

 

Partnered

Single

Separated

 

Divorced

 

Widowed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

13.ASSESSOR/CM: Current Physical Location Address (If type is a facility, enter facility name.)

a. Street:

 

 

b. City:

 

 

 

 

 

 

 

 

 

 

c. ZIP code:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

d. Type:

 

 

 

Private residence

 

Assisted living facility (ALF)

 

Nursing facility

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hospital

 

Adult day care

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

e. Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

14.

Home Address (If different from current physical location)

 

 

 

 

 

 

 

 

 

 

 

a. Street:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b. City:

 

 

 

 

 

 

 

 

 

 

 

 

 

c. ZIP code:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

15.

Is client’s home address public housing? No Yes

 

 

 

 

 

Mailing Address (If different from current physical location)

 

 

 

 

 

16.

 

 

 

 

 

 

 

 

 

 

 

a. Street:

 

 

 

 

 

 

 

b. City:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c. State:

 

 

 

 

 

 

 

 

d. ZIP code:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1DOEA 701B, April 2013

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