Form Sfy01 - Adult Day Services - Planned Services printable pdf download

Form Sfy01 - Adult Day Services - Planned Services

Revised 8/17/00

Adult Day Services

SFY01 Planned Services

Applicant Agency_______________________________________________________________

Adult Day Service Clients in SFY 01

Number of MHT

beneficiaries age 60+ you expect to serve

Number of MHT beneficiaries age 60- you expect to serve

Number of physically frail, non-MHT beneficiaries 60+ you expect to serve

Number of physically frail, non-MHT beneficiaries age 60- you expect to serve

Total Number of Adult Day Service Clients in SFY 01

Hours Of Adult Day Services in SFY 01

Number of hours of adult day services to MHT beneficiaries age 60+

Number of hours of adult day services to MHT beneficiaries age 60-

Number of hours of adult day services to physically frail, non-MHT beneficiaries

age 60+

Number of hours of adult day services to physically frail, non-MHT beneficiaries

age 60-

Total Number of Adult Day Service Hours to be provided in SFY 01

Estimated cost per client per day of service: $_______ per hour of service $_______

Outcome Measures: Describe outcomes that clearly demonstrate the impact of adult day services

on your clients and caregivers. Please attach a copy of the measurement tool, description of how

the information will be gathered, and when a summary report of results will be submitted to the

Alaska Commission on Aging.

Planned dates for conducting NCoA Training for Program Assistants in Adult Day Center

training session: _________________________________________

MHT= Mental Health Trust

GF = grant and other sources of funds

MW = Medicaid Waiver funded

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Form Sfy01 - Adult Day Services - Planned Services