Srs Form Fy1 - Client Characteristics Program Report - Alaska Commission On Aging October 2000

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(Revised 10/5/00)
Quarter ending:
SRS Client Characteristics Program Report
pSept. 30, 2000
p Dec. 31, 2000
FY01 Alaska Commission On Aging
pMarch 31, 2001
pJune 30, 2001
Grantee:
SRS Program:
1st quarter
2nd quarter
3rd quarter
4th quarter
Total
July-Sept.
Oct - Dec
Jan - Mar
April - June
1. Total number of NEW residents
this quarter (include grant, Waiver,
GF
MW
GF
MW
GF
MW
GF
MW
GF
MW
and other source of funds clients)
ADRD client 60+
0
0
ADRD clients under 60
0
0
Mentally ill clients 60+
0
0
Mentally ill clients under 60
0
0
DD clients 60+
0
0
DD clients under 60
0
0
Other cognitive imp. clients 60+
0
0
Other cognitive imp. clients under 60
0
0
Physically frail clients 60+
0
0
Physically frail clients under 60
0
0
2. Number of new residents this
quarter, by Racial/Ethnic identity :
0
A. American Indian/Alaska Native
0
B. Asian/Pacific Islander
0
C. Black
0
D. Hispanic
0
E. White
3. Number of new residents who are
residents of a rural area
0
4. Number of new residents whose
income is below the federal poverty
0
level
5. Total number of people discharged
0
Due to death
0
To a nursing home
0
Other (please list):
0
6. Total number of clients on the
waiting list for services at the end of
the quarter:
7. Number of residents each quarter
who are Medicaid Waiver clients
8. Total number of unduplicated
Medicaid Waiver clients who received
residential services in SFY01
Does this report revise information submitted on earlier reports?___________
If so, please highlight changes.
2
G:\ACoA\SFY 01 New Forms\FY01 HCB forms instructions
8/3/00

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