Carestar Waiver Program Details

Ohio Form Jfs 02390 is a form that is used to request the juvenile probation department to investigate allegations of child abuse or neglect. The form must be completed and submitted by the person reporting the allegations. The purpose of this form is to provide the juvenile probation department with information so that they can determine whether an investigation is necessary. Completed forms should be sent to: Ohio Department of Job and Family Services, Division of Child Protection and Permanency, Investigations Section, 30 E. Broad Street, Suite 320, Columbus, OH 43215-3431.

We have collected some general information about the ohio form jfs 02390. You can browse it prior to submitting the form.

QuestionAnswer
Form NameOhio Form Jfs 02390
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namescarestar ohio home care waiver, undersigned, CMA, 2010

Form Preview Example

Ohio Department of Job and Family Services

HOME CARE ATTENDANT (HCA) SKILLED TASK AUTHORIZATION

Consumer Name (Please print)

Consumer Street Address

Recipient I.D. #

City

State

Zip Code

 

 

 

SKILLED TASKS TRAINING LIST

INSTRUCTIONS FOR TRAINER

Enter the medically necessary skilled task(s) the Home Care Attendant has successfully completed training to perform. Draw a single line through any unused boxes.

INSTRUCTIONS FOR AUTHORIZED HEALTH CARE PROFESSIONAL (AHP)

Place initials in the box for each approved task(s).

TASK

AHP

INITIALS

TASK

AHP

INITIALS

JFS 02390 (7/2010)

Page 1 of 3

SKILLED TASKS APPROVAL

DIRECTIONS

Each team member shown below must complete the section that applies to her/his role. The HCA is not approved to perform the listed task(s) until though AHP has initialed the “Training Detail” page.

CONSUMER/AUTHORIZED REPRESENTATIVE

I, the undersigned have received the necessary training and am electing to select, instruct and direct the Home Care Attendant (HCA) to perform the task(s) set forth on this form. I will ensure that the HCA performs the task(s) consistent with her/his training and in accordance with OAC Rule 5101:3-46-04.1, as appropriate. I understand that this authorization may be revoked at any time by my authorizing health care professional. I am responsible for reporting any changes in my health or circumstances to the Case Management Agency (CMA) Case Manager, Trainer (if other than consumer, HCA, and Authorized Health Care Professional.

Name (Please print)

Signature

Initials

Date Signed

HOME CARE ATTENDANT

I, the undersigned have received training in task(s) set forth on this form, and will perform the task(s) in accordance with OAC Rule 5101:3-46-94.1 or 5101:3-50-04.1, as appropriate, and as trained by the consumer, authorized representative and/or trainer. I understand that I am approved to perform on the listed task(s) for this consumer and that ODJFS may revoke that approval at any time if deemed necessary. I understand I am responsible for reporting any changes in my ability to perform the task(s) to the Consumer, CMA Case Manager, Trainer, and Authorized Health Care Professional.

Name (Please print)

Signature

Initials

Date Signed

TRAINER (Please read before signing and dating)

I, the undersigned, verify that I have successfully trained the Home Care Attendant to perform the task(s) set forth on this form.

Trainer Name (Please print)

Trainer Signature

Initials

Date Signed

AUTHORIZING HEALTH CARE PROFESSIONAL AND TRAINER (Please read before signing and dating)

I, the undersigned, approve the consumer’s decision to select, instruct and direct the Home Care Attendant in the performance of the task(s) set forth on this form. I understand that I may revoke approval at any time, if deemed necessary, by notifying the Consumer/Authorized Representative, CMA Case Manager, and Trainer.

Name (Please print)

Signature

Initials

Date Signed

Emergency Phone Number (Including Area Code)

Fax Number (Including Area Code)

In the event that no physician is aware of or supports the consumer’s decision to use the Home Care Attendant option, the Registered Nurse who is serving as the Authorized Healthcare Professional must be made aware of the physician’s exclusion or non-support.

Customer/Authorized Representative (Initials)

Authorized Healthcare Professional (Initials)

JFS 02390 (7/2010)

Page 2 of 3

SKILLED TASK TRAINING DETAIL

Consumer Name (Please print)

Effective Period (not to exceed 12 months)

 

 

 

 

 

 

Trainer Name (Please print)

Start Date

 

End Date

 

 

 

 

 

 

 

 

DIRECTIONS

Trainer – Enter the name of the medically necessary skilled task required by the consumer. Enter the date the Home Care Attendant (HCA) completed training to successfully perform the skilled task. Write a detailed description of how HCA will perform the task, including times or intervals.

(If the consumer/authorized representative is the trainer, the consumer/authorized representative will complete this section.)

Name of Task

Date Training Completed

 

 

Task Training Detail

 

Check here if CONTINUED on next page

AUTHORIZED HEALTHCARE PROFESSIONAL

My initials indicate approval of this task to be performed by the Home Care Attendant and that the Home Care Attendant has demonstrated the ability to perform the task.

(INITIAL HERE)

JFS 02390 (7/2010)

Page 3 of 3