Form DSHS 02-516 at a glance
What it is: Adult Family Home Resident Personal Belongings Inventory, Aging and Long-Term Support Administration (ALTSA), WAC 388-76-10320.
Who signs: The PROVIDER'S/RESIDENT MANAGER'S SIGNATURE and the RESIDENT'S OR GUARDIAN'S SIGNATURE each go with a DATE.
A filled-in Form DSHS 02-516 example: a provider lists a new resident's belongings
How to fill out Form DSHS 02-516, box by box
Resident's name, guardian and date of admission
Enter the RESIDENT'S NAME, the NAME OF RESIDENT'S GUARDIAN and the DATE OF ADMISSION.
Contact lenses, dentures, eye glasses, hearing aid, jewelry, watch, money and other
Use the boxes for contact lenses, dentures, eye glasses, hearing aid, jewelry, watch, money/checkbook/credit cards and other.
Clothing list
In the CLOTHING LIST, enter the NUMBER and the ITEM DESCRIPTION.
Miscellaneous
In MISCELLANEOUS, enter the NUMBER and the ITEM DESCRIPTION; for a Television or a Wheelchair, enter the model and serial number.
Signing the statement
The statement reads: I have read and agree that this is an accurate list of my belongings.
The PROVIDER'S/RESIDENT MANAGER'S SIGNATURE and the RESIDENT'S OR GUARDIAN'S SIGNATURE each go with a DATE.
More rules for Form DSHS 02-516
The Provider or Resident Manager completes the form 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.
Sources
[1] Form DSHS 02-516 (REV. 07/2017), Adult Family Home Resident Personal Belongings Inventory, Aging and Long-Term Support Administration (the Official source link on this page).