Form Ag-095 - Arizona Standardized Client Assessment Plan (Ascap) Page 7
Download a blank fillable Form Ag-095 - Arizona Standardized Client Assessment Plan (Ascap) in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Ag-095 - Arizona Standardized Client Assessment Plan (Ascap) with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15AG-095 (11-14) – Page 7
CLIENT’S NAME
DAARS ID NO.
COMMENTS
E.
Evacuation Needs Assessment
Evacuation Needs Assessment Instructions
1.
Was the response to ASCAP Part I, Section B, question Household Composition identified as “Lives Alone”?
Yes (go to question #2)
No (go to question #3, select “No”)
2.
Which of the following items have been identified on the ASCAP? (Check the appropriate box(es).)
ASCAP Part IV, Sec. C, Transportation is identified as 3. Mod. Asst. OR 4. Max. Asst., OR the Qualifier “Cognitive” is
identified.
ASCAP Part IV, Sec. C, Transferring is identified as 3. Mod. Asst. OR 4. Max. Asst., OR the Qualifier “Cognitive” is identified.
ASCAP Part IV, Sec. B, Hearing is identified as “Absence of useful hearing.”
ASCAP Part IV, Sec. B, Vision is identified as “No vision or appears to see only light, colors or shapes.”
ASCAP Part IV, Sec. A, Person, Place, Time and/or Recent memory recall are identified as “Disoriented at least half of the
time” or “Severely impaired function and safety.”
ASCAP Part IV, Sec. D, One or more of these items, Cane, Quad Cane, Crutches, Walker, Electric wheelchair, Manual
wheelchair, Electric scooter, Oxygen, Oxygen mask, Portable oxygen or Ventilator, is identified as “Has.”
If one or more of these items are checked, go to question #3 and select “Yes”.
If no items are checked, go to question #3 and select “No”.
3.
In the event of a disaster/emergency where evacuation is required, would the individual be placed on a priority list for evacuation
assistance?
Yes (Case Manager: If you are satisfied with this answer, go to question #4. If you feel that “No” would be a better answer,
select the override box and provide an explanation.)
No (Case Manager: If you are satisfied with this answer, STOP – Process Ends. Go to Part I, Sec. A, Client Profile of this
assessment and mark “No” to “Needs emergency evacuation assistance.” If you feel that “Yes” would be a better answer,
select the override box and provide an explanation.)
Override: Select this box if, in the judgment of the Case Manager, the answer to question #3 should be changed. Explain why
an override of the automatic answer is warranted.
If you selected the override, changing “Yes” to “No,” STOP – Process Ends. Go to Part I, Sec. A, Client Profile of this assessment
and mark “No” to “Needs emergency evacuation assistance.”
If you selected the override, changing “No” to “Yes”, go to question #4.
4.
In the judgment of the Case Manager, and if resources are available during a disaster/emergency requiring evacuation, describe
what evacuation assistance would be required for the individual. Then go to Part I, Sec. A, Client Profile of this assessment and
mark “Yes” to “Needs emergency evacuation assistance.”
PART V: ADDITIONAL FUNCTIONAL ASSESSMENT
Required except for Tribal Services, HDM only, Respite, Supplemental Services and Case Management only.
A. Environmental Problems
Check all that apply.
Accessibility
Fire safety
Plumbing/utilities
Toilet
Animals
Furnishings
Refrigerator/freezer
Tub/shower
Building structure
Heating
Security
Unable to determine
Cleanliness
Hot water
Stairs/handrail
Other
Dryer/washer
Insects/rodents
Stove/burner
None
Evaporative cooler/AC
Microwave/convection oven
Telephone
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal