Targeted Case Management Contact Monitoring Form Page 4
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Complete if Personal Emergency Response System is on the PCSP:
N/A
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30. Do you wear your PERS button?
Yes
No
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31. Would you prefer the necklace or wristband?
Necklace
Wristband
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32. Have you had to push the button?
Yes
No
If yes, why? What happened? When?
________________________________________________________________________________________________
________________________________________________________________________________________________
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33. Did the response center answer quickly?
Yes
No
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34. Does your PERS provider call you every month to test your unit?
Yes
No
PERS Unit tested while TCM was making a home visit.
Response Time: ______________________________
Operator Name:______________________________
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Complete if Adult Day Services or Adult Day Health Services is on the PCSP:
N/A
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35. Do you like participating in day services?
Yes
No
36. How many days each week do you go to the center? ______________________________________________________
37. How many hours each day do you stay at the center? _____________________________________________________
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38. Do you want to continue going the same amount of time?
Yes
No
39. What types of activities do you do at the center?__________________________________________________________
________________________________________________________________________________________________
40. In what ways do the workers involve you in activities?______________________________________________________
________________________________________________________________________________________________
41. How do you travel to the center? ______________________________________________________________________
42. What is your favorite thing(s) about the center? __________________________________________________________
_________________________________________________________________________________________________
43. What do you dislike the most about the center? __________________________________________________________
________________________________________________________________________________________________
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Complete if Respite Care is on the PCSP (
):
N/A
Please address questions to the primary caregiver
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44. Do you receive respite care ?
Yes
No
If yes, from whom?___________________________________________
45. How often do you receive respite care?_________________________________________________________________
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DMS-690 (1-1-16)
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