Respite Client Characteristics Form - Alaska Commission On Aging, Home Community Based Services - 2001
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2Alaska Commission on Aging, Home Community Based Services
Respite Client Characteristics
SFY 2001
Quarter ending:
pSept. 30, 2000
pDec. 31, 2000
pMarch 31, 2001
Grantee: _______________________________________________
pJune 30, 2001
1st quarter
2nd quarter
3rd quarter
4th quarter
Respite Services
Totals
July-Sept.
Oct - Dec
Jan. - March
April - June
1. Total Number of NEW Respite Clients (including grant,
Waiver, and other sources of funds clients)
ADRD clients 60+
ADRD clients under 60
Mentally ill clients 60+
Mentally ill clients under 60
DD clients 60+
DD clients under 60
Other cognitively impaired clients 60+
Other cognitively impaired clients under 60
Physically frail clients 60+
Physically frail clients under 60
2. Number of NEW respite clients by Racial/Ethnic identity :
A. American Indian/Alaska Native
B. Asian/Pacific Islander
C. Black
D. Hispanic
E. White
3. Number of NEW respite clients who reside in a rural area
4. Number of NEW respite clients whose income is below
the federal poverty level
5. Number of respite clients discharged this quarter
6. Total number of clients on waiting list for any respite
services at end of quarter
7. Total number of respite clients on waiting list for more
services at end of quarter
Does this report revise numbers submitted on earlier reports?___________
If so, please highlight revision(s).
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