Form 3613 A ≡ Fill Out Printable PDF Forms Online

Form 3613 A PDF Details

Form 3613 A, also known as the "Employee's Withholding Allowance Certificate," is a document used by employers to determine an employee's withholding allowances. The form must be completed by the employee and submitted to the employer. This article will provide an overview of Form 3613 A and instructions on how to complete it. It's important for employees to understand how their wages are taxed so they can plan ahead for their financial future. By completing Form 3613 A, employees can ensure that their correct withholding allowances are being taken into account by their employer.

The listing provides details about the form 3613 a. Before you decide to fill out the form, it is definitely worth examining a little more about it.

Question	Answer
Form Name	Form 3613 A
Form Length	4 pages
Fillable?	Yes
Fillable fields	240
Avg. time to fill out	24 min 32 sec
Other names	3613a pdf, 3613 a, dads forms, texas form 3613 a

12

Form Preview Example

Provider Investigation Report

For use only by Skilled Nursing Facilities (SNF), Nursing Facilities (NF), Intermediate Care Facilities for Individual with an Intellectual Disability or Related Conditions (ICF/IID), Assisted Living Facilities (ALF), Adult Day Care Facilities (ADC), and Day and Activity Health Services Facilities (DAHS).

Fax Cover Sheet

Date:

To: DADS Consumer Rights and Services Section

Attention: Intake Coordinator

Fax Area Code and Telephone No.: 1-877-438-5827

Regarding DADS Intake ID No.:

No. of Pages, including cover:

		From:
	Provider Name:						Vendor / ID No.:
	Street Address:
		City:
	Telephone No.:			–	–
		Fax:		–	–

				Provider Investigation Report Information


Agency Name							License No.

Street Address

City, State, ZIP Code							County

Area Code and Telephone No.			Fax Area Code and Telephone No.
–	–			–	–	Parent	Branch/Alternate Delivery Site
–	–			–	–

Confidential Document:

This communication (including any attached document) contains privileged and/or confidential information. If you are not an intended recipient of this communication, please be advised that any disclosure, dissemination, distribution, copying or other use of this communication or any attached document is strictly prohibited. If you have received this communication in error, please notify the sender immediately and promptly destroy all copies of this communication and any attached documents.

Use only for Skilled Nursing Facilities (SNF), Nursing Facilities (NF),

Intermediate Care Facilities for Individuals with an Intellectual Disability or Related Conditions (ICF/IID),

Assisted Living Facilities (ALF), Adult Day Care Facilities (ADC),

and Day and Activity Health Services Facilities (DAHS).

Form 3613-A/ 07-2012

	Texas Department of Aging	SNF, NF, ICF/IID, ALF, ADC, DAHS
	and Disability Services
		Provider Investigation Report

Fax this report to: 1-877-438-5827 (toll free) or

Mail this report to: Texas Department of Aging and Disability Services, Consumer Rights and Services Section, E-249, P.O. Box 149030, Austin, TX 78714-9030

Form 3613-A

July 2012

Note to reporter:

Do not mail if faxed.

DADS Intake ID No.

Date Reported to DADS 800-458-9858

Time Reported

:

A.M.

P.M.

Provider Type

Vendor / ID No.

Telephone No.

–

–

Name

Fax

–

–

Street Address

City

ZIP Code

Incident Category

Death

Abuse

Neglect

Exploitation

Missing Resident/Individual

Drug Diversion

Fire

Bomb Threat

Tornado

Flood

Emergency Power Failure

Sprinkler System Failure

Fire Alarm Failure

Firearms in the Building

Air Conditioning Failure if Outdoor Temperature is or will be 90 Degrees or Above

Heating System Failure if Outdoor Temperature is 65 Degrees or Below

Others, specify

Who made the allegation?

When?

Individual /Resident

Family

Other

Incident Date

Time

Location

:

A.M.

P.M.

Individual(s)/Resident(s) Involved, Including Alleged Victim(s) or Alleged Aggressor(s)

Name

Female

Male

Social Security No.

Date of Birth

Functional Ability:

Total assistance

Extensive

Minimal

No assistance

Level of Supervision:

No special supervision

Within eyesight

Within hearing

Within arm’s length

Within specified distance:

Specified observation time frame:

Other:

Independently ambulatory

Y

N

Interviewable

Y

N Capacity to make informed decisions

Y

N

History of

Combativeness

Verbal aggression

Physical aggression

Sexual misconduct

Wandering

Wearing wander guard at time of incident

Y

N

Similar allegations

Other pertinent history:

Name

Female

Male

Social Security No.

Date of Birth

Functional Ability: Level of Supervision:

Total assistance

No special supervision Within specified distance: Other:

Extensive	Minimal	No assistance
Within eyesight	Within hearing	Within arm’s length
	Specified observation time frame:

Independently ambulatory		Y
History of	Combativeness
	Wandering

Other pertinent history:

N	Interviewable	Y	N	Capacity to make informed decisions
	Verbal aggression		Physical aggression			Sexual misconduct
Wearing wander guard at time of incident				Y	N	Similar allegations

Y N

Name

Female

Male

Social Security No.

Date of Birth

Functional Ability:

Total assistance

Extensive

Minimal

No assistance

Level of Supervision:

No special supervision

Within eyesight

Within hearing

Within arm’s length

Within specified distance:

Specified observation time frame:

Other:

Independently ambulatory

Y

N

Interviewable

Y

N

Capacity to make informed decisions

Y

N

History of

Combativeness

Verbal aggression

Physical aggression

Sexual misconduct

Wandering

Wearing wander guard at time of incident

Y

N

Similar allegations

Other pertinent history:

Form 3613-A

Page 2 / 07-2012

DADS Intake ID No.

Alleged Perpetrator(s) (AP)

(If alleged perpetrator is somebody other than a staff member, indicate this individual’s relationship to the person. Example: relative, visitor, etc.)

Name

Date of Birth

Social Security No.

License/Certificate No.

	How was the AP identified?	By name	By description	Other:

	Perpetrator:	Denied	Confirmed	History of similar allegations?			Yes	No
	Did investigation reveal the presence of a witness?						Yes	No
	Did investigation reveal the presence of a witness?						Yes	No
	Statement attached (signed and notarized, if possible)						Yes	No


	Witness(es) Name	Individual/Patient/Family/Staff/Other		Address		Area Code and Telephone No.
						–	–
						–	–
						–	–
						–	–

Description of the Allegation

....................................................................................................................................................Injury/Adverse Effect?	Yes	No

Description of Injury

Assessment

Date

Time

:

A.M.

P.M.

Description of Assessment

			Treatment/Transfer Date	Time
Treatment provided?	Yes	No		:	A.M.	P.M.
			Off-site		City
Treatment location: In-House	Yes	No

Provider Response

Form 3613-A

Page 3 / 07-2012

DADS Intake ID No.

Investigation Summary (attach additional sheets, as necessary)

Investigation Findings

Confirmed

Unconfirmed

Inconclusive

Unfounded

Provider Action Taken Post-Investigation

Signature

Printed Name

Title

Date

How to Edit Form 3613 A Online for Free

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Step 1: Click the "Get Form Here" button.

Step 2: You are now on the form editing page. You can edit, add information, highlight certain words or phrases, insert crosses or checks, and add images.

Type in the essential material in every segment to create the PDF 3613 a provider investigation report

part 1 to filling in texas self report 3613

Indicate the information in County, Fax, Area, Code, and, Telephone, No Parent, Branch, Alternate, Delivery, Site City, State, ZIP, Code Area, Code, and, Telephone, No Confidential, Document and Form, A

part 2 to entering details in texas self report 3613

Note the necessary data in Date, Reported, to, DADS Time, Reported Vendor, ID, No City, Telephone, No, Fax ZIP, Code Bomb, Threat Drug, Diversion, Fire, Alarm, Failure Fire, Firearms, in, the, Building Abuse, Neglect, Emergency, Power, Failure Exploitation, and Flood field.

texas self report 3613 DateReportedtoDADS, TimeReported, VendorIDNo, City, TelephoneNoFax, ZIPCode, BombThreat, DrugDiversionFireAlarmFailure, Fire, FirearmsintheBuilding, Abuse, Neglect, EmergencyPowerFailure, Exploitation, and Flood fields to complete

The Functional, Ability Level, of, Supervision No, special, supervision Within, eyesight Within, hearing Total, assistance Extensive, Minimal, No, assistance, Within, arms, length Name, Name, Within, specified, distance Other, Specified, observation, timeframe and Independently, ambulatory, History, of field will be the place to put the rights and obligations of both parties.

Filling out texas self report 3613 step 4

Look at the fields Functional, Ability, Level, of, Supervision Total, assistance, No, special, supervision Extensive, Within, eyesight Minimal, Within, hearing Specified, observation, timeframe No, assistance, Within, arms, length Within, specified, distance Other, Independently, ambulatory Interview, able N, Capacity, to, make, informed, decisions History, of Combative, ness Verbal, aggression and Physical, aggression and then complete them.

Entering details in texas self report 3613 step 5

Step 3: After you select the Done button, your finished document can be easily transferred to all of your devices or to electronic mail provided by you.

Step 4: To prevent different problems in the long run, be sure to prepare at least several duplicates of the file.

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