Database Coversheet - North Carolina



This form should accompany all NC-SNAP assessments. Please complete all applicable sections of the form. A copy of this form, along with a copy of the NC-SNAP assessment, should be forwarded to the responsible LME-MCO for keying into the NC-SNAP database. After data entry, the forms should be filed and maintained per documentation requirements. Date of NC-SNAP Assessment: FORMTEXT ?????Individual’s Name: FORMTEXT ?????Type of Assessment (check only one)Individual’s Unique ID No. FORMTEXT ????? FORMCHECKBOX Initial Assessment FORMCHECKBOX Special UpdateIndividual’s Case No. FORMTEXT ????? FORMCHECKBOX Annual UpdateMedicaid ID No. FORMTEXT ????? FORMCHECKBOX State funded Services FORMCHECKBOX Money Follows Person FORMCHECKBOX Other _____________________________ FORMCHECKBOX Change in DD Support Status (if applicable, check only one) FORMCHECKBOX Deceased FORMCHECKBOX Refused Services FORMCHECKBOX Unable to Locate FORMCHECKBOX Moved to AnotherLME-MCO FORMCHECKBOX Moved Out-of-State FORMCHECKBOX No Longer Receiving Services (other) FORMCHECKBOX Changed Provider (name): FORMTEXT ????? FORMCHECKBOX SIS Assessment (date completed) Current NC-SNAP Scores Daily Living: FORMTEXT ?Health Care: FORMTEXT ?Behavioral Supports: FORMTEXT ?Overall Level: FORMTEXT ?Examiner/Agency Information Examiner’s Name: FORMTEXT ?????Agency Name: FORMTEXT ?????NC-SNAP Certification No. FORMTEXT ?????Agency Address: FORMTEXT ?????Examiner’s Email: FORMTEXT ?????Agency Phone: FORMTEXT ?????Individual’s Type of Residential Placement (check only one) FORMCHECKBOX Independent Living (lives by self or with roommate) FORMCHECKBOX Family Home (lives with family member or guardian) FORMCHECKBOX Foster Home FORMCHECKBOX 1 Bed Alternative Family Living (AFL) FORMCHECKBOX 2 - 6 Bed Alternative Family Living (AFL)Supervised Living DD Adult Group Home (state funded) FORMCHECKBOX 1 - 3 Bed Supervised Living DD Adult FORMCHECKBOX 4 - 6 Bed Supervised Living DD AdultSupervised Living DD Minor Group Home (state funded) FORMCHECKBOX 1 - 3 Bed Supervised Living DD Minor FORMCHECKBOX 4 - 6 Bed Supervised Living DD MinorICF/ID Group Home (Medicaid funded) FORMCHECKBOX 1 - 6 Bed ICF/ID Group Home FORMCHECKBOX 7 - 15 Bed ICF/ID Group Home FORMCHECKBOX > 15 Bed ICF/ID Group HomeAdult Care/Nursing/Rest Homes (homes for aged/disabled) FORMCHECKBOX 1 - 6 Bed Adult Care/Nursing/Rest Home FORMCHECKBOX 7- 15 Bed Adult Care/Nursing/Rest Home FORMCHECKBOX > 15 Bed Adult Care/Nursing/Rest HomeLarge Congregate Care (> 15 Bed) FORMCHECKBOX State Developmental Center FORMCHECKBOX Psychiatric Hospital FORMCHECKBOX Neuro Med Treatment CenterOther Residential Not Listed Above (Specify Below) FORMCHECKBOX 1 - 6 Bed Other Residential FORMCHECKBOX 7-15 Bed Other Residential FORMCHECKBOX > 15 Bed Other Residential Specify Other Residential FORMTEXT ?????Oct 2017 ................
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