Form Dshs 02 516 PDF Details

When individuals enter an Adult Family Home, it's crucial to ensure their personal belongings are meticulously accounted for, a task undertaken through the completion of the DSHS 02-516 form by the Aging and Long-Term Support Administration (ALTSA). This essential document, designed to be filled out upon a resident's admission, plays a pivotal role in safeguarding the personal items of those in care. It covers a wide range of belongings from essentials like contact lenses, dentures, and hearing aids, to personal items including jewelry and clothing. The form also extends to miscellaneous items such as mobility aids and electronics, ensuring a comprehensive inventory is taken. Both the provider or resident manager and the resident—or their guardian or agent—are required to sign this form, asserting the accuracy of the listed items. Moreover, this form underscores the commitment to privacy, stipulating that these records be managed in a way that maintains the confidentiality of the residents’ information. This process not only facilitates a smooth transition into the facility by reassuring residents and their families but also establishes a clear record that can be referenced if disputes about belongings arise. The DSHS 02-516 form is a testament to the conscientious care and detailed attention Adult Family Homes dedicate to those they serve, highlighting an important aspect of resident management and care coordination.

QuestionAnswer
Form NameForm Dshs 02 516
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other nameswashington dshs inventory, resident inventory form, resident inventory sheet, dshs home personal inventory

Form Preview Example

AGING AND LONG-TERM SUPPORT ADMINISTRATION (ALTSA)

Adult Family Home Resident Personal Belongings Inventory

WAC 388-76-10320

Instructions: Provider or Resident Manager completes upon admission. The Provider/Resident Manager and the resident or the resident’s guardian or agent sign. File in the resident’s record. Records and information concerning each person in care shall be maintained in such a manner as to preserve confidentiality.

RESIDENT’S NAME

NAME OF RESIDENT’S GUARDIAN

DATE OF ADMISSION

 

 

 

CONTACT LENSES

DENTURES

 

 

 

 

EYE GLASSES

HEARING AID

 

 

 

 

JEWELRY

WATCH

 

 

 

 

MONEY/CHECKBOOK/CREDIT CARDS

OTHER

 

 

 

 

 

 

CLOTHING LIST

NUMBER

ITEM

DESCRIPTION

 

Bathrobe

 

 

Belt

 

 

Blouse

 

 

Brassiere

 

 

Coat

 

 

Dress

 

 

Girdle

 

 

Gloves

 

 

Handkerchief

 

 

Hat

 

 

House coat

 

 

Necktie

 

 

Nightgown

 

 

Pajamas

 

 

Pants

 

 

Shirts

 

 

Shoes

 

 

Skirts

 

 

Slippers

 

 

Slips

 

 

Socks

 

 

Stockings

 

 

Suit

 

 

Suspenders

 

 

Sweater

 

 

Undershirt

 

 

Underpants

 

 

Underwear - long

 

 

Vests

 

 

Other:

 

 

 

MISCELLANEOUS

NUMBER

ITEM

DESCRIPTION

 

Brush

 

 

Cane or crutches

 

 

Clock

 

 

Luggage

 

 

Radio

 

 

Television (model and serial number)

 

 

Walker

 

 

Wheelchair (model and serial number)

 

 

Other:

 

Statement: I have read and agree that this is an accurate list of my belongings.

PROVIDER’S/RESIDENT MANAGER’S SIGNATURE DATE

RESIDENT’S OR GUARDIAN’S SIGNATURE

DATE

 

 

DSHS 02-516 (REV. 07/2017)

How to Edit Form Dshs 02 516 Online for Free

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So as to fill out this document, be sure you enter the necessary information in every blank field:

1. Start filling out your adult family home resident personal belongings with a selection of necessary blank fields. Get all of the required information and make sure there's nothing forgotten!

Part number 1 of submitting resident inventory sheet

2. Once your current task is complete, take the next step – fill out all of these fields - NUMBER, NUMBER, Bathrobe Belt Blouse Brassiere, MISCELLANEOUS, DESCRIPTION, ITEM, Brush Cane or crutches Clock, Statement I have read and agree, RESIDENTS OR GUARDIANS SIGNATURE, DATE, DATE, and DSHS REV with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

Completing part 2 of resident inventory sheet

Always be very attentive when filling out Statement I have read and agree and DATE, since this is where most people make a few mistakes.

Step 3: When you have looked over the information you filled in, press "Done" to conclude your FormsPal process. After starting a7-day free trial account with us, you will be able to download adult family home resident personal belongings or send it through email without delay. The file will also be readily available in your personal account page with all your edits. FormsPal is invested in the privacy of all our users; we make sure all personal data put into our tool remains protected.

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