If you are a business owner in the State of New York, you may be required to file a Lic 603 form. This form is used to report information about your business, including its ownership and operating structure. Filing this form can help ensure that your business is in compliance with New York state laws. Here's what you need to know about the Lic 603 form and how to file it.
You can find more information concerning the lic 603 form by checking out the listing our team put together.
| Question | Answer |
|---|---|
| Form Name | Lic 603 Form |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | preplacement appraisal, preplacement information online, lic 603, lic 603a |
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY |
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES |
|
COMMUNITY CARE LICENSING |
PREPLACEMENT APPRAISAL INFORMATION
Admission - Residential Care Facilities
NOTE: This information may be obtained from the applicant, or his/her authorized representative. (Relatives, social agency, hospital or physician may assist the applicant in completing this form.) This form is not a substitute for the Physician’s Report (LIC 602).
APPLICANT’S NAME
AGE
HEALTH (Describe overall health condition including any dietary limitations)
PHYSICAL DISABILITIES (Describe any physical limitations including vision, hearing or speech)
MENTAL CONDITION (Specify extent of any symptoms of confusion, forgetfulness: participation in social activities (i.e., active or withdrawn))
HEALTH HISTORY (List currently prescribed medications and major illnesses, surgery, accidents; specify whether hospitalized and length of hospitalization in last 5 years)
SOCIAL FACTORS (Describe likes and dislikes, interests and activities)
BED STATUS
■
■
■
OUT OF BED ALL DAY
IN BED ALL OR MOST OF THE TIME IN BED PART OF THE TIME
COMMENT:
TUBERCULOSIS INFORMATION
ANY HISTORY OF TUBERCULOSIS IN APPLICANT’S FAMILY? |
DATE OF TB TEST |
■ POSITIVE |
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■ YES |
■ NO |
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■ NEGATIVE |
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ANY RECENT EXPOSURE TO ANYONE WITH TUBERCULOSIS? |
ACTION TAKEN (IF POSITIVE) |
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■ YES |
■ NO |
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GIVE DETAILS |
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LIC 603 (9/99) |
(Over) |
AMBULATORY STATUS (this person is ■ ambulatory ■ nonambulatory)
Ambulatory means able to demonstrate the mental and physical ability to leave a building without the assistance of a person or the use of a mechanical device. An ambulatory person must be able to do the following:
YES NO
■■ Able to walk without any physical assistance (e.g., walker, crutches, other person), or able to walk with a cane.
■■ Mentally and physically able to follow signals and instructions for evacuation.
■■ Able to use evacuation routes including stairs if necessary.
■■ Able to evacuate reasonably quickly (e.g., walk directly the route without hesitation).
FUNCTIONAL CAPABILITIES (Check all items below)
YES |
NO |
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■ |
■ |
Active, requires no personal help of any kind - able to go up and down stairs easily |
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■ |
■ |
Active, but has difficulty climbing or descending stairs |
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■ |
■ |
Uses brace or crutch |
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■ |
■ |
Feeble or slow |
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■ |
■ |
Uses walker. If Yes, can get in and out unassisted? |
■ Yes |
■ No |
■ |
■ |
Uses wheelchair. If Yes, can get in and out unassisted? |
■ Yes |
■ No |
■■ Requires grab bars in bathroom
■■ Other: (Describe)
_______________________________________________________________________________________________________________
SERVICES NEEDED (Check items and explain)
YES NO
■ ■
■ ■
■ ■
■ ■
■ ■
■ ■
■ ■
■ ■
■ ■
■ ■
■ ■
■ ■
■ ■
■ ■
■ ■
Help in transferring in and out of bed and dressing________________________________________________________________________
_______________________________________________________________________________________________________________
Help with bathing, hair care, personal hygiene ___________________________________________________________________________
Does client desire and is client capable of doing own personal laundry and other household tasks (specify) ___________________________
Help with moving about the facility ____________________________________________________________________________________
_______________________________________________________________________________________________________________
Help with eating (need for adaptive devices or assistance from another person) _________________________________________________
_______________________________________________________________________________________________________________
Special diet/observation of food intake _________________________________________________________________________________
_______________________________________________________________________________________________________________
Toileting, including assistance equipment, or assistance of another person_____________________________________________________
Continence, bowel or bladder control. Are assistive devices such as a catheter required? _________________________________________
Help with medication _______________________________________________________________________________________________
_______________________________________________________________________________________________________________
Needs special observation/night supervision (due to confusion, forgetfulness, wandering) _________________________________________
Help in managing own cash resources _________________________________________________________________________________
Help in participating in activity programs ________________________________________________________________________________
_______________________________________________________________________________________________________________
Special medical attention ___________________________________________________________________________________________
_______________________________________________________________________________________________________________
Assistance in incidental health and medical care _________________________________________________________________________
_______________________________________________________________________________________________________________
Other “Services Needed” not identified above ___________________________________________________________________________
_______________________________________________________________________________________________________________
Is there any additional information which would assist the facility in determining applicant’s suitability for admission? |
■ Yes |
■ No |
If Yes, please attach comments on separate sheet. |
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To the best of my knowledge; I (the above person) do not need skilled nursing care.
SIGNATURE
DATE COMPLETED
APPLICANT (CLIENT) OR AUTHORIZED REPRESENTATIVE
SIGNATURE
DATE COMPLETED
LICENSEE OR DESIGNATED REPRESENTATIVE
DATE COMPLETED