Form 10-2406 - Recommendation For Release Of Patient In Home Other Than Patient'S Own - Department Of Veterans Affairs Page 2

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MILITARY SERVICE
39. COMBAT
35. BRANCH OF SERVICE
36. LENGTH OF SERVICE
37. HIGHEST RANK OR
38. DATE OF LAST DISCHARGE
ACTION
GRADE
YES
NO
PART III (To be completed by the Social Worker)
HOSPITAL AND EMPLOYMENT HISTORY
41. TYPE OF HOSPITALIZATION OTHER
40. LENGTH OF HOSPITALIZATION PRIOR TO AND
41. LENGTH OF HOSPITALIZATION SINCE
THAN VA
DURING MILITARY SERVICE
DISCHARGE FROM MILITARY SERVICE
PRIVATE
STATE
NONE
43. BRIEF HISTORY OF EMPLOYMENT PRIOR TO AND AFTER DISCHARGE FROM MILITARY SERVICE
PATIENT'S READINESS FOR PLACEMENT
44. PATIENT'S AND RELATIVES ATTITUDE TOWARD THIS PLACEMENT
45. PATIENT'S WORK ASSIGNMENTS, HOBBIES AND OTHER REHABILITATION ACTIVITIES
46. ABILITY OF PATIENT TO ASSIST WITH HOUSEHOLD TASKS
47. CLUB MEMBERSHIPS AND OTHER ASSOCIATIONS
48. PRESENT AND PAST CHURCH ACTIVITES
49. NAMES OF PERSONAL FRIENDS INTERESTED IN PATIENT
50. ADDRESSES
51. PATIENT'S SPECIAL NEEDS, CAPACITIES, PROBLEMS, ETC.
52. TYPE OF HOME AND COMMUNITY DESIRED
53. KIND OF SUPERVISION AND PERSONAL ATTENTION REQUIRED BY PATIENT IN THE HOME
54. DESIRABLE QUALITIES IN THE PERSON ASSUMING RESPONSIBILITY FOR THE PATIENT
55. PREFERRED AGE RANGE
56. RECOMMEND PLACEMENT OF VETERAN IN
57. SHOULD EMPLOYMENT IN THE NEIGHBORHOOD BE ENCOURAGED
RURAL AREA
URBAN AREA
YES
NO
58. SIGNATURE OF SOCIAL WORKER
59. DATE
10-2406
VA FORM
PAGE 2 OF 2
MAY 2003

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