Respite Client Characteristics Form - Alaska Commission On Aging, Home Community Based Services - 2001 Page 2
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2Alaska Commission on Aging, Home Community Based Services
Respite Client Characteristics
SFY 2001
Quarter ending:
___________________________________________
Grantee: _
pSept. 30, 2000
p Dec. 31, 2000
pMarch 31, 2001
pJune 30, 2001
1st quarter
2nd quarter
3rd quarter
4th quarter
Respite Services
Total
July-Sept.
Oct - Dec
Jan - Mar
April - June
8. Total number of respite clients served this quarter
on Medicaid Waiver
9. Total number of unduplicated Medicaid Waiver
clients receiving respite services at any time during
SFY01
10. Total Hours of Respite Services
GF
MW
GF
MW
GF
MW
GF
MW
GF
MW
Hours to ADRD 60+
Hours to ADRD under 60
Hours to Mentally ill 60+
Hours to Mentally ill under 60
Hours to DD 60+
Hours to DD under 60
Hours to Other cog. imp 60+
Hours to Other cog. imp. under 60
Hours to Physically frail 60+
Hours to Physically frail under 60
Please highlight the revisions .
Does this report revise information submitted on earlier reports?_______
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