REVISED: 09/25/09



DESCRIPTIONCODE.THOMAS ALLEN LETTERHEAD1-PAGE PROFILE – THOMAS ALLEN (BLACK&WHITE)SR/1306B-7161-PAGE PROFILE – THOMAS ALLEN (COLOR)SR/1306A-716AC FEE LETTERCM/1403-421ACCOUNTING FOR DISCLOSURESSR/1406-822ACTIVE LEISURE PARTICIPATIONSO/941-706ACTIVITY LOGGINGSSO/944-505ADAPTIVE EQUIPMENT MONITORING TOOLSR/1508-707ADMISSION DISCHARGE AND STATUS CHANGE CM/106-119ADMISSION DISCHARGE AND STATUS CHANGE (CONS/GUARD)CONS/106-318ADMISSION MEETING SUMMARY SR/107-920AGREEMENT TO PROVIDE SERVICESSR/105.3-618ALCOHOLIC BEVERAGE CONSENT FORMSO/1305-107ANNUAL ACCOUNTING – DAKOTACONS/451.1-0105ANNUAL CHECKLIST AND FLOWCHART SO/454-916ANNUAL INFORMATIONAL STATEMENTCONS/441.1-810ANNUAL SUMMARY OF SKILLS AND NEEDS (ICF/MR ONLY)ICF/1010.2-706ARCHIVE REQUESTSO/1586-1005ASSESSMENT INFORMATION CHECKLISTHEN/220-706ASSESSMENT OF CLIENT INTERESTSSO/954-408ASSESSMENT OF STAFF TRANSFER TECHNIQUES USING AN EZ/LIFT-U-UP/GET-U-UP DEVICESR/250-215ASSESSMENT OF STAFF –VAN LIFT OPERATIONS & WHEELCHAIR SECUREMENT TECHNIQUESSR/202-914ASSESSMENT OF VAN LIFT OPERATION AND WHEELCHAIR SECUREMENT-DEERVIEWDV/1350-921ASSESSMENT SUMMARY – GUIDELINES FOR COMPLETIONSR/220.1-706AUDIT SCHEDULE 2022SO/1470-123AUTHORIZATIONSR/403.1-403AUTHORIZATION FOR DIGITAL COMMUNICATIONSR/400-618AWAKE NIGHT COUNSELOR TASKS JS/848.1102BASSETT CREEK RECORD OF STAFF TRAINING IN USE OF MEDICAL EQUIPMENTBC/43-918BEDROOM FURNISHINGSSR/301-517BEHAVIORAL ASSESSMENT OF INDEPENDENT LIVING SKILLSSO/211-1222BILLING ATTESTATIONSR/1461B-719BLANK CALENDAR – LANDSCAPE SO/1370-0889BUSINESS ASSOCIATE AGREEMENTSR/1400-611CALENDAR OF MAJOR CLIENT, STAFF OR DIVISION ACTIVITIESSO/1180-307CARE COORDINATION SERVICES SATISFACTION SURVEYCM/450.1-417CASE CLOSING – GUARDIAN & CONSERVATORCONS/155-618CASE CLOSING – GUARDIAN & REP PAYEECONS/157-618CASE CLOSING – GUARDIAN ONLYCONS/156-618CASE INITIATION – GUARDIAN & CONSERVATORCONS/150-618CASE INITIATION – GUARDIAN & REP PAYEECONS/152-618CASE INITIATION – GUARDIAN ONLYCONS/151-618CASE MANAGEMENT CASE BOOK AUDIT (CADI/TBI)CM/462-306CASE MANAGEMENT CASE BOOK AUDIT (CADI/TBI-HENNEPIN)CM/463-306CASE MANAGEMENT CASE BOOK AUDIT (EW)CM/465-306CASE MANAGEMENT FILE AUDIT DD (RULE 185)CM/464-212CASE MANAGEMENT SERVICES SATISFACTION SURVEYCM/450.2-417CASE MANAGEMENT SPECIFIC INDIVIDUAL RIGHTSCM/1460-121CASE MANAGER’S COST REPORTCM/520-706CASE REVIEW SCATTERED SITESSILS/452.1-1014CERTIFICATE OF SELF-PRESERVATIONFC/709CHECK REQUESTSO/1593-0398CHECKING ACCOUNT RECEIPTSO/581.1-1003CLASSIFICATIONS OF PSYCHOTROPIC MEDICATION AS OF 2011 SO/710-913CLIENT FINANCIAL AUDIT REPORT SR/540-108CLIENT LOGGINGSSO/641-505CLIENT PERSONAL RECORD SR/402-323CLIENT PHYSICAL EXAMINATION SR/705.1-816CM MES AGREEMENT LETTERCM/504-322CM/MC ANNUAL MEETING FORM FOR VERBAL CONSENTCM/403.4-321COMMON ACRONYMSSO/1380-219COMMUNITY LIVING SERVICES – SERVICE RECIPIENT LOGGINGSO/643-223COMPASS – MINNESOTA BILLING SHEETCOMPASSMN-0105COMPETENCY TEXT – SPECIAL DIETARY REQUIREMENTS – PROGRAM SPECIFICSL/20.1-816COMPLAINT AND DISCRIMINATION POLICY (Hmong)CM/1461-621 (Hmong)COMPLAINT AND DISCRIMINATION POLICY (Russian)CM/1461-721 (Russian)COMPLAINT AND DISCRIMINATION POLICY (Somali)CM/1461-621 (Somali)COMPLAINT AND DISCRIMINATION POLICY (Spanish)CM/1461-121 (Spanish)CONSENT FOR PICTURES TO BE USED ON THE INTERNET SR/404-108CONSENT FOR THE RELEASE OF CONFIDENTIAL INFORMATIONSR/403-321 (English)CONSENT FOR THE RELEASE OF CONFIDENTIAL INFORMATIONSR/403-621 (Hmong)CONSENT FOR THE RELEASE OF CONFIDENTIAL INFORMATIONSR/403-621 (Somali)CONSENT FOR THE RELEASE OF CONFIDENTIAL INFORMATION SR/403-721 (Russian)CONSENT FOR THE RELEASE OF CONFIDENTIAL INFORMATION (CASE MGMT USE)CM/403.1-317 (CM)CONSENT TO EXTEND ANNUAL PLANSSO/1000-806CONSUMER SATISFACTION SURVEY – CASE MANAGEMENT SERVICESCM/406-909CONTACT SCHEDULESILS/1170-411CONTRACTED CASE MANAGEMENT SERVICES SURVEY – COUNTY REPRESENTATIVESCM/400-1007CONTROLLED MEDICATIONS ACCOUNTABILITY RECORDSR/741-203CONTROLLED SUBSTANCESSR/709-914COST ALLOCATION FORMSR/593-420COVID RETURN TO IN-PERSON MEETINGS-GUARDIANSCM/1464.2-721COVID RETURN TO IN-PERSON MEETINGS-PERSONS SERVEDCM/1464.1-721CSSP ADDENDUM - GUIDELINES FOR COMPLETION SR/1010.1-214DAKOTA COUNTY COVER SHEETCM/1598.2-413DAKOTA COUNTY SOCIAL SERVICES BILLING STATEMENTCOCNS/1040-409DAKOTA COUNTY SUSPECTED CHILD MALTREATMENT REPORTING FORMSS/WAR-1021-0490DATA SHEET COMPLETION INSTRUCTIONSAVE/606-1195DAY PROGRAM ATTENDANCESR/1250-1222DEATH OR SERIOUS INJURY REPORTSR/1469-418DEATH OR SERIOUS INJURY REPORT cover page (PDF)SR/1469-418DELEGATION COACHING AND MONITORING TOOLSO/1590-407DENIAL OF REQUEST TO ACCESS RECORDSSR/1401-316DENTAL REFERRAL FORM SO/703.1-908DESIGNATED COORDINATOR REVIEW OF SERVICESSR/690-1122DESIGNATED COORDINATOR REVIEW OF SERVICES-COMM. LIVING SERVICESSR/691-123DHS – VARIANCE REQUESTSR/1461-807DISABILITY PARKING CERTIFICATE LETTERSR/860-212DISASTER PREPAREDNESS KIT QUARTERLY CHECKLISTSR1553-1211DISCHARGE CHECKLIST - ICF/MRICF/126-907EMERGENCY BACK-UP PLANCM/706.2-611EMERGENCY PHONE LIST SILS/455-212EMERGENCY PHONE NUMBERS OAK/390-1216EMERGENCY PHONE NUMBERS SO/390-1216EMERGENCY USE OF A MANUAL RESTRAINTSR/1005.7-214EMPLOYMENT HISTORYSO/1205-0622EXPENDITURE REPORTSO/548-1016EZ LIFT SAFETY & MAINTENANCE CHECKLISTSR/850.3-1112FAX COVER SHEET SR/1598-1201FAX COVER SHEET - CASE MANAGEMENT SR/1598.1-900FILE AUDIT: INDIVIDUAL CLIENT RECORDS - ICF/MR ICF/450.1-413FILE AUDIT: INDIVIDUAL CLIENT RECORDS RULE 18 (SILS) SILS/450-203FILE AUDIT: INDIVIDUAL RECORDS - RULE 245DSR/450-419FILE AUDIT: SUB-CONTRACTED CLIENT RECORDS – CONSOLIDATED STANDARD (SUPPORT SERVICES)SS/450-413FILE AUDIT: WAIVERED CLIENT RECORDS - SUPPORT SERVICESSS/450.4-212FILE AUDIT: CLIENT RECORDS – RULE 245D – SUPPORT SERVICES, SCATTERED SITESSR/450.5-423FINANCIAL LOGGINGSSO/543-505FIRE AND TORNADO DRILL REPORT – SITE SPECIFIC EMERGENCY PROCEDURESSR/342-619FIRE SYSTEM EQUIPMENT CHECKLIST – THIRD AVE/CORNER PLACE TA/343-1002FOOD INVENTORY MISCELLANEOUSSO/351-103FORMS REVIEW SR/1650-1022FUNCTIONAL ASSESSMENT SES/204-415FUNCTIONAL ASSESSMENTSO/204-705FUNCTIONAL ASSESSMENT SUMMARYSO/203-505FUNCTIONAL BEHAVIOR ASSESSMENTSO/208-216GENERAL LOGGINGSSO/642-109GRIEVANCE REPORTSR/1320-214GUARDIAN, FAMILY & SOCIAL WORKER SATISFACTION SURVEYSILS/407-403HEALTH CARE PLANSO/712-414HEALTH MAINTENANCE REPORTED INCIDENTS SR/1044-901HEALTH NEEDS NOTIFICATION LOGSR/708.1-115HENNIPEN CDCS DECISION MEMOCM/410-522HEPATITUS B RISK ACKNOWLEDGEMENT BBAS/2035-219HIPAA BREACH LETTERSR/1402.1-1217HIPAA BREACH REPORTSR/1402-118HISTORY OF THOMAS ALLENSR/100-618HOME MANAGEMENT/MAINTENANCE PROGRAM STAFFSR/850.1-214HOUSEHOLD ACCOUNT WOORKBOOK (excel version)SO/593-614HOUSEHOLD EQUIPMENT MONITORINGSR/1509-707HOUSEHOLD FINANCIAL AUDIT REPORTSR/598-807HOUSEHOLD ITEMS FOR PROGRAM START UPSR/1555-1109HOUSING WITH SERVICES CONTRACTSILS/105-610HOYER LIFT TRANSFER ASSESSMENTSR/201-818ILS GOAL STATEMENTSILS/1310-707ILS GOAL STATEMENT (DAKOTA COUNTY)SILS/1310.2-411ILS GOAL STATEMENT (W/DEMOGRAPHIC BOX)SILS/1310.1-411IN CASE OF DEATH AND BURIAL SO/405-323INCIDENT REPORT - NON-VULNERABLE ADULT SR/1021-323INDIVIDUAL ABUSE PREVENTION PLAN SR/211-922INDIVIDUAL ABUSE PREVENTION PLAN FOR ADULT FOSTER CARESR/211.2-423INTAKE AND DEMISSION DATA FOR CLIENT SR/106.1-718INTENSIVE SUPPORT SERVICES ASSESSMENT AND SUMMARYSR/220-1122INTENSIVE SUPPORT SERVICES ASSESSMENT AND SUMMARY FOR SUPPORTED EMPLOYMENT SERVICES (SES)SR/220.4-315INTERNAL FILE AUDIT: INDIVIDUAL CLIENT RECORDS (SILS)SILS/450.1-807INVITATION REQUEST FOR CLIENT REVIEW MEETINGSO/1035-1003ISP FACE SHEETCM/1013-707ITEMS REQUIRING FINANCIAL DIRECTOR’S APPROVALSR/1590-215LEAVE DAYSO/750-123LEISURE RECORDSO/942-1205LICENSING INFORMATION BY COUNTY, RULE, PROGRAM & CLIENTSO/1406-822LIVE-IN COUNSELORS DAMAGE DEPOSIT AGREEMENTSR/300-304MAINTENANCE CHECKLIST SR/850-123MAINTENANCE NEEDS QUADRANTSR820-212MAINTENANCE PRE-EMPLOYMENT TESTMAINTENANCE REQUEST/REPLY FORMSR/890-403MAINTENANCE STAFF SIGN IN SHEET SR/852-212MAINTENANCE/ROUTINE DAILY LIVING GOALSSO/617-807MAJOR START UP PURCHASESSR/1557-1109MALTREATMENT OF VULNERABLE ADULT INCIDENT REPORTSR/1022-717MEDICAL APPOINTMENTS RECORDSR/748-403MEDICAL ITEMS FOR PROGRAM START UPSSR/1555.1-1109MEDICAL MONITORING TOOLSO/740-307MEDICATION AND TREATMENT ADMINISTRATION RECORD DOCUMENTATION SHEETSO/700.3-314MEDICATION DESTRUCTION FORMOAK/780-816MEDICATION ERROR REPROTSR/720-418MEETING AVAILABILITY TRACKING TOOLSO/1131-307MENU PLANNINGSO/310-908MONTHLY MAINTENANCE ACCOUNT ANALYSIS SR/592-214MONTHLY REVIEW OF OBJECTIVESSR/616-1111MOVE/DEATH NOTIFICATION TO COURTCONS/1024-618NEED AREAS AND OBJECTIVES (ICF/MR ONLY)ICF/1010.3-706NEUROLEPTIC MALIGNANT SYNDROME (NMS) INFORMATION SHEETSR/710.11-206NEW HIRE SUPPLY CHECKLISTCM/50-419NON-VULNERABLE ADULT/MALTREATMENT OF MINORS REPORTED INCID.SR/1046.1-306NOTICE OF PRIVACY PRACTICESSR/101-321NOTICE OF SERVICE TERMINATIONSR/181-0919NOTICE OF TEMPORARY SERVICE SUSPENSIONSR/180-1015NURSING CARE PLAN/ASSESSMENT AND QUARTERLY REVIEW BC/720-803OMBUDSMAN SERIOUS INJURY REPORT FORM SR/ 1467-112ONE PAGE CLIENT PROFILESR/206-216ORDER SHEET FOR CLIENT FILES/BOOKS/MISC PROGRAM MATERIALSSR/1592-117OUTCOME MEASURES REFERENCE GUIDE SR/1029.1-201OXBURY TIME CARDOXB/36-611PAGE DIVIDER ORDER FORM CM/1581-1002PAGE DIVIDER ORDER FORM – CADI/TBI CM/1580-1002PAGE DIVIDER ORDER FORM – RULE 185CM/1582-106PEER GROUP SUMMARYSILS/943-807PERMANENT FILE AUDIT: CLIENT RECORDS RULE 203/CONSOLIDATED RULE FC/450.1-909PERSON CENTERED PLANNING TOOL (PCPT) SR/1029-922PERSON CENTERED PLANNING TOOL (PCPT) FOR NON-VERBAL/LOWER FUNCTIONING CLIENTSSR/1029.2-1020PERSONAL ITEM TRANSFER - CLIENT DISCHARGESO/155-0290PET OWNERSHIP AGREEMENTSR/1300-716PETTY CASH SLIPSO/581-1003PHYSICIAN RATIONALE FOR MEDICATIONSO/710.1-206PHYSICIAN’S INSTRUCTIONS (FOR MEDS NOT TAKEN AS DIRECTED)SR/700-505PHYSICIAN’S REPORT - EMERGENCY USE OF A CONTROLLED PROCEDURESR/1005.8-1014POLICY BOOK CHANGE SR/1595-1022PRN (PRO RE NATA) “AS NEEDED” BEHAVIORAL AND PROCEDURAL CRITERIASR/710.9-206PRN USAGE REPORTSR/710.1-916PROGRAM ABUSE PREVENTION PLANSR/209.1-1115PROGRAM CHART (QUARTER) SR/1140-JFM21(ETC.)PROGRAM COMMENTS SR/643-806PROGRAM DATA AND MONTLY REVIEW OF OBJECTIVES (MRO) (3 MONTH)SO/616.2-517PROGRAM DATA AND MONTLY REVIEW OF OBJECTIVES (MRO) (FULL PAGE)SO/616.1-517PROGRAM DIRECTOR ON-SITE REVIEW SR451-1022PROGRAM FILES CHECKLIST – CONSOLIDATED STANDARD & 203 PROGRAMS FC/450-108PROGRAM FILES CHECKLIST – CONSOLIDATED STANDARD (NO FOSTER CARE)SS/451-108PROGRAM FILES CHECKLIST - RULE 18 PROGRAMS (SILS) SO/450-203PROGRAM ITEMS TO PURCHASESR/1556-1109PROGRAM MANAGER’S TASK DUE DATESSR/1171-522PROGRESS REPORT - GUIDELINES FOR COMPLETION SR/1027.1-214PROPERTY & VEHICLE REPORTSR/1000-505PSYCHOTROPIC DATA SUMMARYSR/710.6-206PSYCHOTROPIC MEDICATION EVALUATION APPOINTMENTSR/703.1-1222PSYCHOTROPIC MEDICATION HISTORYSO/709.6-206PSYCHOTROPIC MEDICATION REVIEWSR/1024-115QUARTERLY HEALTH CARE EXAMINATION ICF/1028-207RAMSEY COUNTY COVER SHEETCM/1598.3-413RECAPITULATION SUMMARY AND DESCRIPTION OF SERVICESCONS/440.1-109RECORD OF STAFF MANTOUXICF/22.2-609REFERRAL QUESTIONNAIRE SR/105-618REFERRAL SUMMARY SR/105.1-1117REFERRAL SUMMARY – SEAS SEAS/105.1-202RENEWAL INFORMATION FOR FINANCE 6790SR/506-119REPORT OF CHANGE CM/1023-302REQUEST FOR ACCOUNTING OF DISCLOSURESSR/406-403REQUEST FOR GENERAL OFFICE SUPPLIESSR/1590-1004REQUEST FOR REVISION TO ISPSR/220.3-609RESPITE/FOSTER CARE AGREEMENT SS/105-1201REVISION TO PROVIDER IMPLEMENTATION PLANSO/602-308RIGHTS RESTRICTION PLANSR/403.2-717RISK MANAGEMENT ASSESSMENT AND PLAN – DAKOTA COUNTY BEST PRACTICESDD-DAK697-2RISK MANAGEMENT ASSESSMENT AND PLAN – DAKOTA COUNTY HELPFUL HINTSDD-DAK697-3RISK MANAGEMENT ASSESSMENT AND PLAN – DAKOTA COUNTY INTERPRETIVE GUIDEDD-DAK697-1ROOMMATE AGREEMENTSR/305-617ROUTING SLIP SR/1599-921ROUTING SLIP PROGRAM SR/1599.1-103SAFETY & EMERGENCY PROCEDURES REVIEW GUIDELINESSILS/1029-908SAFETY TEST OUT USING Q’STRAINTSSR/1350-914SATISFACTION SURVEY SR/450.1-1122SATISFACTION SURVEY – CONS/GUARD CLIENTCONS/290.1-821SATISFACTION SURVEY – CONS/GUARD CONSUMERCONS/290.2-821SATISFACTION SURVEY – GUARDIANSHIP & CONSERVATORSHIPCONS/290-618SATISFACTION SURVEY – SUPPORT SLS PROVIDERSSS/450.1-1013SATISFACTION SURVEY RESULTS SR/450.4-420SATISFACTION SURVEY TALLY SO/450.3-420SCATTERED SITES CLIENT CONTACT LOG SILS/440-307SEIZURE LOGSO/722.1-307SEIZURE REPORT SO/722-403SEMI-ANNUAL POSITIVE SUPPORT STRATEGY EVALUATIONSR/690.1-420SERIOUS INJURY REPORT SR/1467-619SERIOUS INJURY REPORT COVER PAGE (PDF)SR/1467-619SERVICE OUTCOME GUIDLINES SR/617.2-517SERVICE OUTCOME PLAN SR/617-922SERVICE OUTCOME PLAN WHEN PSYCHOTROPIC MEDICATIONS ARE PRESCRIBEDSR/709.5-922SERVICE PLAN REVIEW MEETING SUMMARYSR/1027.2-922SERVICE PLAN REVIEW REPORT SR/1027-922SERVICE RECIPIENT LEDGER AND EXPENDITURE REPORT SO/520-423SERVICE TERMINATION SUMMARY SR/126-1015SES BILLING SHEETSES/1045-715SES/1029-719SILS PROGRAM FILES ADMISSION CHECKLIST SILS/451-108SILVER OAKS NUTRITION ASSESSMENT FORMOAK/781-314SITE SPECIFIC EMERGENCY PROCEDURESSR/1342-914SLS ITEMS TO POSTFC/1551-1109SPEND DOWN LETTER – CASE MANAGEMENTCM/591-622SPEND DOWN LETTER 3ACM/590.3A-714SPEND DOWN LETTER 3BCM/590.3B-1222STAFF SIGNATURE PAGESO/1309.1-1119STAFF TRAININGSR/110-616STANDING ORDERS FOR OVER THE COUNTER/PRN MEDICATIONS SR/771-216STATEMENT OF ACKNOWLEDGEMENTS SR/109-1118SUMMARY OF SERVICESSO/1592-607SUPPORT PLAN ADDENDUM (SPA)SR/1010A-922SUPPORT PLAN ADDENDUM (SPA-B) – CONSENTS PACKETSR/1010B-123SUPPORT SERVICES TIME SHEETSS/36-821SUPPORT SERVICES TIME SHEET – MULTIPLE CLIENTS SS/36.1-121SUPPORT TEAM MAILING LIST SR/106-618SUPPORTING SCHEDULE : COUNTY INVOICE FOR OBRA LEVEL 2CM/1506-1118TAI CELL PHONE CHECK OUTSR/1506-906TARDIVE DYSKINESIA (TD) INFORMATION SHEETSR/709.2-206TEMPORARY STAFFING AGENCYSR1301-1022TIME REPORTSR/1045-1106TIME REPORT/DIRECT TIME SILS/1045-1116TRAINING DOCUMENTATION CASE MANAGEMENT & MANAGED CARE (EXCEL VERSION)CM/40-323TRAINING DOCUMENTATION CASE MANAGEMENT & MANAGED CARE (WORD VERSION)CM/40-522TRANSFER OF CASE TO CONSERVATOR ASSISTANTCONS/1593-618VAN QUARTERLY CHECKLISTSR/1553.2-219VAN SAFETY TEST OUT USING Q’STRAINT RETRACTORSSR/1350-309VEHICLE ACCIDENT REPORT GUIDE SR/1021.1-212VOCATIONAL LOGGINGSSO/1244-505VULNERABLE ADULT/MALTREATMENT OF MINORS REPORTED INCIDENTSSR/1046-323VULNERABLE ADULTS ACT SUMMARY SR/160-1118WATER ASSESMENTSO/251-223WATER TEMPERATURE REVIEW SR/851-409WORK SUBMITTED - REQUEST TABS SILS/1591-606WORKSLIPSR1591-921 ................
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