Are you a Texas resident trying to get your hands on Form 3599? Look no further! This blog post will provide an overview of what the form is and why it is important. We'll explain what Form 3599 includes, who should use it, and answer some common questions about filing taxes in the Lone Star State. With this guide, you can be sure that you have all the information you need for a successful tax season in Texas. Keep reading to learn more about Texas Form 3599!
| Question | Answer |
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| Form Name | Texas Form 3599 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | Texas, you form 3599, orientation supervisory visits, 2012 |
Texas Department of Aging |
Community Living Assistance and Support Services (CLASS) |
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and Disability Services |
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Habilitation Service Provider Orientation/Supervisory Visits |
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Individual’s Name (please print) |
Date |
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Frequency of supervisory visits Habilitation service provider name |
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Delegated habilitation service provider |
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Habilitation service provider |
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Special habilitation service provider orientation by telephone
Form 3599
September 2013
Purpose of Visit
PO SV
Describe the individual’s functional limitations that require a need for habilitation services. (Complete when orienting habilitation service
1. provider)
2. Orientation (complete when orienting habilitation service provider):
Habilitation service provider instructed about individual’s health condition and how it may affect provision of tasks. |
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Habilitation service provider instructed about tasks to be provided, work schedule and safety and emergency |
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procedures. |
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Habilitation service provider |
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instructed to report to |
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(Print name and credentials) |
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(Telephone no.) |
The following health and safety concerns (document concerns):
Note: In the event of an emergency, notify 911.
Individual hospitalized |
Other: |
Changes in individual’s needs and behavior
Individual absent from home or moved
Habilitation service provider unable to work scheduled hours
Habilitation service provider schedules
Schedule 1
Type Of Service |
Monday |
Tuesday |
Wednesday |
Thursday |
Friday |
Saturday |
Sunday |
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Weekly Total Habilitation Hours
Schedule 2
Type Of Service
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Weekly Total Habilitation Hours
Form 3599
Page 2 /
Individual’s Name (please print)
3.A. Tasks/Plan of Care: Indicate tasks to be performed (complete on every visit). During supervisory visit, ask individual or LAR what tasks are provided by the service provider. Observe or ask about performance: S = Satisfactory U = Unsatisfactory
Hygiene..............
Toileting.............
Dressing.............
Shopping ...........
Meal Preparation
Freq. Perform.
Feeding ..........................
Exercise .........................
Transfer/Ambulation......
Cleaning .........................
Community Assistance
Freq. Perform.
Medically Related Tasks......
Freq. Perform.
3.B. Is the habilitation service provider competent to provide habilitation tasks? |
Yes |
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3.C. Is the habilitation service provider competent to provide delegated habilitation tasks? |
Yes |
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3.D. Is the habilitation service provider competent to provide medically related tasks? |
Yes |
Complete the following for Supervisory Visits (N/A for habilitation service provider orientation only).
4. |
Is the individual satisfied with the services provided by the habilitation service provider? |
Yes |
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5. |
Is the habilitation service provider following the schedule? |
Yes |
6.A. |
Describe service delivery problems. |
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No
No
No
No No
N/A
N/A
N/A
6.B. Describe habilitation service provider training needs.
6.C. Describe corrective actions taken.
7. Does the individual continue to need services? ...........................................................................................................
8. Additional Comments:
Yes
No
Signature – Individual/LAR |
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Date |
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Signature – Habilitation Service Provider |
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Date |
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Signature – Supervisor |
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Date |