Lic 603 Form – Fill Out and Use This PDF

Lic 603 Form is a PDF file that you can download from the website. It has different fields for recording relevant details about your business, such as its name and address.

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Lic 603 Form PDF Details

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?	Yes
Fillable fields	127
Avg. time to fill out	25 min 58 sec
Other names	lic 603a, preplacement appraisal, lic 603 pdf, lic 603

12

Form Preview Example

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(Specify extent of any symptoms of confusion, forgetfulness: participation in social activities (i.e., active or withdrawn))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
			■ POSITIVE
■ YES	■ NO		■ NEGATIVE

ANY RECENT EXPOSURE TO ANYONE WITH TUBERCULOSIS?		ACTION TAKEN (IF POSITIVE)
■ YES	■ NO

GIVE DETAILS

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
■	■	Active, requires no personal help of any kind - able to go up and down stairs easily
■	■	Active, but has difficulty climbing or descending stairs
■	■	Uses brace or crutch
■	■	Feeble or slow
■	■	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.

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

How to Edit Lic 603 Form Online for Free

With the goal of allowing it to be as easy to apply as possible, we designed this PDF editor. The process of creating the lic 603a can be simple when you adhere to the next actions.

Step 1: Press the orange "Get Form Now" button on this page.

Step 2: At this point, you're on the form editing page. You can add text, edit present information, highlight particular words or phrases, insert crosses or checks, insert images, sign the form, erase unrequired fields, etc.

The next parts are inside the PDF form you will be completing.

preplacement appraisal spaces to fill out

Note the details in BED, STATUS OUT, OF, BED, ALL, DAY IN, BED, ALL, OR, MOST, OF, THE, TIME IN, BED, PART, OF, THE, TIME YES, COMMENT, DATE, OF, TB, TEST ACTION, TAKEN, IF, POSITIVE YES, GIVE, DETAILS LI, C Over, POSITIVE, and NEGATIVE.

step 2 to filling out preplacement appraisal

You have to write particular data in the area non, ambulatory ambulatory, YES, YES, Uses, brace, or, crutch Feeble, or, slow Yes, Yes, Requires, grab, bars, in, bathroom and Other, Describe

Finishing preplacement appraisal step 3

You will have to describe the rights and obligations of both parties in space Other, Describe SERVICES, NEEDED, Check, items, and, explain YES, and Help, in, managing, own, cash, resources

Entering details in preplacement appraisal part 4

Finalize by reading all of these areas and completing the appropriate data: Yes, SIGNATURE, LICENSEE, OR, DESIGNATED, REPRESENTATIVE DATE, COMPLETED DATE, COMPLETED and DATE, COMPLETED

Filling in preplacement appraisal step 5

Step 3: As soon as you've hit the Done button, your file will be ready for upload to any kind of gadget or email address you specify.

Step 4: Create duplicates of the file - it may help you keep clear of potential future complications. And don't get worried - we are not meant to reveal or view the information you have.

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