Lic 603 Preplacement Appraisal Information 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.

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QuestionAnswer
Form NameLic 603 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namespreplacement appraisal, preplacement information online, lic 603, lic 603a

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(Specify extent of any symptoms of confusion, forgetfulness: participation in social activities (i.e., active or withdrawn))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

 

 

 

■ 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

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