Form Dhsr/ac 4207 - Resident Register (Page 3 of 4) in pdf

DHSR/AC 4207 (Rev. 09/11) NCDHHS

d. PAST WORK AND VOLUNTEER SERVICE___________________________________________________________

HOBBIES________________________________________________________________________________________

ACTIVITY INTERESTS: (Review Listing of Suggested Activities with resident).

Favorites

Games

Music

Exercises

Outdoor Activity

Crafts

Outings

Social Activity

Work Type/Volunteer Activity

Intellectual Activity

g. ACTIVITIES STRONGLY DISLIKED OR TO BE AVOIDED:_____________________________________________

_________________________________________________________________________________________________

If there is a question about a resident’s ability to participate in an activity, the home must obtain a statement from

the resident’s physician regarding the resident’s capabilities.

D. REQUEST FOR ASSISTANCE

Below are some areas in which the home can assist a resident upon the request of the resident or his/her responsible

person. The administrator or supervisor-in-charge/administrator-in-charge must explain and complete each statement

with the resident or his/her responsible person. The resident or his/her responsible person may subsequently change

his/her mind and make a new request in writing at any time using Section H or some other notice. An equivalent

signed record can be substituted for Section D.

1. I, as resident or the resident’s responsible person, request that pertinent information be secured from the facility from

which I just left. Signature:________________________________________________________________________

2. I, as resident or the resident’s Legal guardian/payee, request that the management of this home handle my personal

funds. I understand that the funds are available for my use during regular office hours and that I have the right to

examine my account or to withdraw this request at any time. Signature:_____________________________________

3. I, as resident or the resident’s responsible person, request the use of lockable space for the security of personal

valuables. I understand that I am entitled to one key at no charge and this space is accessible only to me and the

administrator or supervisor-in-charge. Signature:_______________________________________________________

4. I, as resident or the resident’s responsible person, request that the management of this home –

a. Open my personal mail in my presence to read and explain the contents to me; and

b. Assist in handling my mail that pertains to my financial or medical affairs.

Signature:______________________________________________________________________________________

E. RECEIPT OF MATERIALS

I, as resident or the resident’s responsible person, acknowledge receipt of the following information which the

management of the home reviewed with me:



Home’s resident contract specifying rates for the resident services and accommodations;



House Rules which include policies on refunds, smoking, alcohol consumption, visitation, and reasons for

discharge;

Form Dhsr/ac 4207 - Resident Register Page 3