2008 Consumer Assessment - Lakewood



-2387600004229100-142875For office use only.Para Plan ___Peer Place____Called_____Packet Sent _______400000For office use only.Para Plan ___Peer Place____Called_____Packet Sent _______LAKEWOOD RIDES1580 Yarrow St.Lakewood, CO 80214-6029303.987.4826 - phone303.987.4841 – faxLakewoodRides@Supported by Older Americans Act010668000Please print your name in the space provided and initial each item, sign and date the bottom of this form.I, ___________________________________________, a resident receiving service through the Lakewood Rides program acknowledge and understand as outlined below:_____ I understand that my registration information will be stored electronically with an online scheduling service for the purpose of coordinating routes and schedules used by Lakewood Rides personnel._____ I understand that all my personal information will be kept confidential and that all electronic files are password protected._____ I understand that the hosting software company will have limited access to information stored by Lakewood Rides to service and maintain the software used by Lakewood Rides.I, ___________________________________________, a resident receiving service through the Lakewood Rides program give permission as outlined below: _____ I understand that in the event of an emergency, unusual circumstance or other unusual event, Lakewood Rides’ personnel may contact 911 and/or my designated emergency contact. If necessary, my registration information and related medical status at the time of the event will be given. The sharing of information with these contacts will allow for appropriate medical attention and assistance.________________________________________________________Participant SignatureDate _______________________________________ _________________Guardian SignatureDateIf an individual receiving services from Lakewood Rides is unable to independently sign and acknowledge all items above, a signature from an authorized guardian is requested.Basic Intake Form Welcome! Please tell us a bit about yourself so we can offer services that best meet your needs. We ask for demographic information to meet requirements from our funders. All your personal information is confidential. Please see the attached FAQs for more information and guidance on filling out this form. Contact & Demographic Information:Last Name: FORMTEXT ?????????? First Name: FORMTEXT ?????????? M.I. FORMTEXT ??????????Date of Birth: FORMTEXT ?????????? Age: FORMTEXT ??????????Gender: FORMCHECKBOX Male FORMCHECKBOX Female FORMCHECKBOX Other gender not listed: FORMTEXT ??????????Home Address Line 1: FORMTEXT ??????????Line 2 (Apt/Unit/Floor #): FORMTEXT ??????????City: FORMTEXT ??????????Zip: FORMTEXT ?????????? County: FORMTEXT ?????????? State: FORMTEXT ??????????Mailing Address Line 1: FORMTEXT ??????????Line 2 (Apt/Unit/Floor #): FORMTEXT ??????????City: FORMTEXT ??????????Zip: FORMTEXT ?????????? County: FORMTEXT ?????????? State: FORMTEXT ??????????Location Comments (additional directions for home or mailing address): FORMTEXT ?????Home Phone: FORMTEXT ??????????Cell Phone: FORMTEXT ??????????Email: FORMTEXT ??????????Primary language: FORMCHECKBOX English FORMCHECKBOX Spanish FORMCHECKBOX Other: FORMTEXT ?????Ethnicity: FORMCHECKBOX Hispanic or Latino FORMCHECKBOX Not Hispanic or Latino Race, select all that apply: FORMCHECKBOX American Indian/Alaska Native FORMCHECKBOX Native Hawaiian or Pacific Islander FORMCHECKBOX Asian or Asian American FORMCHECKBOX White FORMCHECKBOX Black or African American FORMCHECKBOX Other not listed: FORMTEXT ?????Do you live: FORMCHECKBOX Alone FORMCHECKBOX With OthersNumber of people in your household (including you): ???? FORMTEXT ?????Is your income above or below the amount listed for your household size: FORMCHECKBOX Above FORMCHECKBOX At/BelowHousehold SizeMonthly IncomeAnnual Income1$1,073$12,8802$1,452$17,4203$1,830$21,9604$2,208$26,500For each additional person, add $4,540 to annual income Emergency Contact:Primary Emergency Contact:Name: FORMTEXT ??????????Phone: FORMTEXT ?????????? Relationship: FORMTEXT ?????????? Interest in Other Services:Health Insurance (select all that apply): FORMCHECKBOX Medicaid FORMCHECKBOX Medicare FORMCHECKBOX Other FORMCHECKBOX NoneAre you interested in learning about nutrition and a healthy diet? FORMCHECKBOX Yes FORMCHECKBOX NoWould you like to hear about other services? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, how can we contact you? FORMCHECKBOX Email FORMCHECKBOX Mail FORMCHECKBOX PhoneWhat services are you interested in? FORMTEXT ????? FORMTEXT ?????Emergency Contacts:Secondary Emergency Contact or Caregiver (if applicable):Name: FORMTEXT ??????????Phone: FORMTEXT ?????????? Relationship: FORMTEXT ??????????Are you visually impaired (can’t be corrected with glasses)? FORMCHECKBOX Yes FORMCHECKBOX NoDo you use any assistive devices? Select all that apply: FORMCHECKBOX None FORMCHECKBOX Ambulatory FORMCHECKBOX Cane FORMCHECKBOX Crutches FORMCHECKBOX Service Animal FORMCHECKBOX Oxygen FORMCHECKBOX Pacemaker FORMCHECKBOX Scooter FORMCHECKBOX Hearing Aids FORMCHECKBOX White Cane FORMCHECKBOX Walker FORMCHECKBOX Wheelchair FORMCHECKBOX Powerchair FORMCHECKBOX Other: FORMTEXT ??????????Are you able to climb 3 or 4 steps into a bus? Yes ? NO ?Will you travel with a Personal Care Attendant (PCA)? Yes ? NO ?Do you need assistance with daily living and personal care? Yes ? NO ?How did you hear about our services? FORMCHECKBOX AAA Brochure FORMCHECKBOX AAA Newsletter FORMCHECKBOX Channel 9 Senior Source FORMCHECKBOX Congregate Meal Site FORMCHECKBOX From a Current Client FORMCHECKBOX From a Friend/Relative FORMCHECKBOX Senior Fair FORMCHECKBOX Walk-In? FORMCHECKBOX Web Site FORMCHECKBOX Other: FORMTEXT ??????????Disclosures and WaiversI have been informed of the policies regarding voluntary contributions, complaint procedures and appeal rights. I am aware that in order to receive requested services, it may be necessary to share information with other departments or service provider and I herewith give my consent to do so. Signature: FORMTEXT ?????????? Date: FORMTEXT ??????????For Office Use Only – (If filled out by assessor or via phone, please have assessor check here and sign below FORMCHECKBOX )Filled Out By: FORMTEXT ?????????? Date: FORMTEXT ??????????Client: Keep this page for your recordsClient Information and FAQs SheetWe are so glad you found us! Please keep this information for your records. Provider and Area Agency on Aging Information: Your Service Provider: Lakewood Rides Program: City of Lakewood Your local Area Agency on Aging: Denver Regional Council of Governments (DRCOG) What is an Area Agency on Aging?We’re glad you asked! The Area Agency on Aging (AAA) is a regional agency that is designated by the state to administer federal, state, and local funding to meet the needs of older adults in their community. The AAA provides programs and services to older adults and caregivers directly and through contracts with community provider agencies. AAAs also serve as advocates for older adults. Service Information:The service you are requesting is funded through the Older Americans Act (OAA) and/or Older Coloradans Act (OCA) funding. This federal and state funding helps older adults, 60+, remain in their homes and communities of choice. Requests for services are processed as funds allow. We can provide you with referrals to other resources in your area, but we will not reach out to them without your permission. What is the purpose of this form?We ask you to fill-in this form for several reasons:To help us learn about you so we can offer services that best meet your needsTo help us understand the needs of older adults in our communityTo help us show the need for funding our programs To help us meet reporting requirements from our fundersTaxpayer money funds these programs. We must prove that the funding only serves eligible clients and targets older adults and caregivers most in need of services. This paperwork helps us meet that level of accountability. Income information is not used to determine your eligibility for services. Income and other demographic information (e.g. gender, race, ethnicity) are collected for anonymous demographic reporting purposes. None of your personal information, such as your name or date of birth is disclosed in reporting. You have the right to refuse to provide any of the information requested on the form. What happens with my information?We enter your information into a secure state database. As you receive services, we record the services you received in the database. This helps us prove how we spent the funding. The database is secured to the standards outlined in Health Insurance Portability and Accountability Act (HIPAA) and Health Information Technology for Economic and Clinical Health Act (HITECH). This means your data remains safe and confidential. Will you sell my information?No. We will never sell your information. How do I provide feedback?We love hearing how we can improve. Contact your service provider at 303-987-4826 or lakewoodrides@. Because we value your input, we may at times send you a survey to ask for your feedback. How do I file a complaint, grievance, or appeal?Complaint/Grievance/Appeal Procedure: You have the right to file a complaint or grievance with the organization asking you to fill out this form. If you are not satisfied with the organization’s decision, you can appeal the decision to your local Area Agency on Aging (AAA), and/or the State Unit on Aging (SUA). The complete Complaint/Grievance/Appeal Procedures are available upon request by contacting your local AAA and/or the SUA as follows:Denver Regional Council of Governments, Area Agency on Aging1001 17th Street, Suite 700Denver, CO 80202303.455.1000Colorado Department of Human Services, State Unit on Aging1575 Sherman Street, 10th FloorDenver, CO 80203303.866.2800 Can I make a financial contribution?We accept contributions to help defray the cost of services and to support our efforts. Every dollar we receive goes back into the programs and services. Contributions are voluntary and are not required to receive services. You can send contributions to Lakewood Rides, 1580 Yarrow Street, Lakewood, CO 80214 What other resources are available?Feel free to reach out to your Area Agency on Aging to get more information about the services available in your region. We love to help! For information about available services in the region, you can contact:DRCOG, Aging and Disability Resource Center (ADRC)Call (303) 480-6700 or e-mail AreaAgencyonAging@You can also call the statewide Aging and Disability Resources for Colorado (ADRC) for information about resources in your area: 1-844-COL-ADRC / 1-844-265-2372 How can I help?We couldn’t meet the needs of older adults in our communities without the amazing help from volunteers and members of our Regional Advisory Councils. Reach out to either your provider or your AAA to see how you can help make a difference in the lives of older adults in our community. Discrimination Complaint Procedure for City of Lakewood/Lakewood Rides Program Any person who believes she or he has been discriminated against based on race, color, or national origin by the City of Lakewood’s (COL) Lakewood Rides Program may file a Title VI complaint by completing and submitting the Title VI Complaint Form. The COL’s Lakewood Rides Program investigates complaints received no more than one hundred and eighty (180) days after the alleged incident. The COL’s Lakewood Rides Program will process complaints that are complete. Once the complaint is received, the Older Adult and Transportation Supervisor and the Family Services Manager will review the complaint to determine if our office has jurisdiction. The complainant will receive an acknowledgement of the letter informing her/him whether the complaint will be investigated by our office. The assigned staff has ten (10) days to investigate the complaint. If more information is needed to resolve the case, the complainant will be contacted. The complainant has five (5) business days from the date of the contact to send requested information to the investigator assigned to the case. If the investigator is not contacted by the complainant or does not receive the additional information within five (5) business days, the investigator can administratively close the case. A case can also be administratively closed if the complainant no longer wishes to pursue their case. After the investigator reviews the complaint, she/he will issue one of two letters to the complainant: a closure letter or a letter of finding (LOF). A closure letter summarizes the allegations and states that there was not a Title VI violation and that the case will be closed. An LOF summarizes the allegations and the interviews regarding the alleged incident, and explains whether any disciplinary action, additional training of the staff member or other action will occur. If the complainant wishes to appeal the decision, she/he has 15 days after the date of the closure letter or the LOF, to do so. Complaints may be submitted via mail, email, and fax or in person to: Dawn Sluder Older Adult and Transportation Supervisor 1580 Yarrow Street Lakewood, Colorado 80214 Phone: 303-987-4832, (TTY: 303-987-4840); Email: dawslu@; Fax: 303-987-4841 Complaints may also be filed directly with the following:City of Lakewood Risk Management 480 South Allison Pkwy Lakewood, Colorado 80226 Contact: Seerie Southwick Phone: (303) 987-7713 Email: seesou@Colorado Department of Transportation Civil Rights & Business Resource Center 4201 East Arkansas Ave., Room 150 Denver, CO 80222 Email: dot_civilrights@state.co.us Phone: (800) 925-3427 Fax: (303) 952-7088Please read the following information concerning this Intake Form and Complaint/Grievance Procedure:We are asking you to complete the attached form to the best of your knowledge so we understand how you would like to receive services. Some basic information (*) is needed to meet compliance with federal and state reporting requirements and to target consumers age 60 and older who have the greatest economic and social need, such as individuals who are low-income minority, frail, and rural. Requests for services are processed as funds allow.Your income level is not used to qualify you to receive services, but rather as a means to gather demographic data to various entities to show the need for continued funding of services. Nobody will contact you, unless you choose so in order to receive information about services which might be available to you.If there is not enough room on the application for any of your responses, please attach a separate plaint/Grievance/Appeal Procedure:The purpose of the Complaint/Grievance/Appeal Procedure isTo ensure fair and equitable treatment of all consumers, eliminate dissatisfaction, resolve problems andTo establish complaint and appeals procedures that inform the consumers of their rights to complain and receive a written response at the provider levelAny OAA/OCA (Older Americans Act/Older Coloradans Act) eligible consumer who has a complaint/grievance with the organization asking you to fill out this assessment form has the right to file a complaint/grievance with said organization and, if not satisfied with the organization’s decision, to appeal that decision with either the local AAA (Area Agency on Aging) or the SUA (State Unit on Aging).The complete Complaint/Grievance/Appeal Procedure is available upon request by contacting your local AAA and/or the SUA as follows: Office of Community Access and IndependenceAging and Adult Services1575 Sherman Street, 10th FloorDenver, CO 80203(303) 866-2800 (main line)(303) 866-2977 (Fax)(888) 866-4243 (Toll Free)Contributions:Any person receiving services shall have the opportunity to contribute towards the cost of the service. No eligible person shall be denied a service because of their inability and/or choice not to contribute.KEEP THIS FORM FOR YOUR RECORDSInstructions about filling out the Basic Consumer Intake Form:This Basic Consumer Intake From is provided as a courtesy to allow the AAAs and their providers to gather the information required by the federal or state government to be entered into Colorado’s official data system (currently PeerPlace). If this information is already obtained by other means, there is no need to fill this Basic Intake Form out again, as long as you have the data to register a client in PeerPlace, by entering the starred (*) data elements into the detailed consumer record.(*) Any fields with this prefix designate demographic data collected by the federal or state government to support the need for continued funding for the various programs. This data will be de-identified and used in aggregate form to compile statistical information. None of the data is sold to a third party and any personal information will only be used in an effort to better serve the client in providing him/her with services.There is one additional required field you need to be aware of, which is not on the form, but needs to be checked in the Financial section under Client Information when you enter the Basic Consumer Intake into PeerPlace. That field is ‘Is the client’s income level below the national poverty level?’ Please check “Yes”, if the either the question above about the monthly individual or household income is answered with “Yes”; mark ‘No’ otherwise.Any fields which do not have the (*) prefix are optional ,but help determine in what other ways we might be able to help the client and to get feed-back about which of our outreach programs are successful. Please try to obtain as much information as possible, since we can only help when we know that there is a need.While we ask you to make an honest effort to gather this basic information, we cannot deny services to clients on the basis of them refusing to provide the requested information, as our programs are not means tested. Since our programs are specifically for the elderly, particularly for persons age 60 or over, the date of birth needs to be filled in. If the client refuses to provide his/her date of birth, please enter 01/01/1901. Then, indicate in the General Comments “client refused to provide DOB, so the default date was entered”.This form may be used for the following workflows (any other workflow requires one of the available assessment forms, rather than just a basic intake):Assisted Transportation/EscortCounselingHealth PromotionInformation and Assistance (if this is entered as an aggregate, no basic intake or registration is needed)Material AidNutrition Education (if this is entered as an aggregate, no basic intake or registration is needed)ReassuranceTransportationOther (service type Screening always needs a basic intake, Education may be entered as aggregate, in which case no basic intake or registration is needed)If you have any questions, please contact your local AAA office. ................
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