[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-176935-105":3,"detail-sidebar-cat-1-en-105":81,"doc-detail-176935-en":127},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":74,"head_meta":76,"extra_data":78,"updated_unix":80},105,"en","a-demographic-section","A. DEMOGRAPHIC SECTION","","Florida Department of Elder Affairs 701B Comprehensive Assessment Demographic Section collects structured client background for assessor/case manager review and care planning. It gathers identifiers and contact details, including Social Security number, Medicaid number, phone, and date of birth, plus sex, ethnicity, primary language, and reading or comprehension limitations for English. It also records marital status and addresses (current physical and mailing), housing/public housing status, caregiver living arrangement, monthly income and asset ranges, special registry enrollment, evacuation assistance needs, and whether responses come from the client or another provider.",{"@graph":14,"@context":73},[15,34,56],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/a-demographic-section/176935/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/a-demographic-section/176935.png","ImageObject",442,249,{"name":42,"@type":43},"WPS_1786070896","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/vnd.openxmlformats-officedocument.wordprocessingml.document","2026-10-23","2026-09-02",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",10,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"What information is collected in the Demographic Section of the 701B assessment?","Question",{"text":63,"@type":64},"The section collects client identifiers, contact details, language and reading ability, sex, ethnicity, marital status, addresses, and relevant living situation details needed for assessment planning.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"How does the form address response assistance from someone other than the client?",{"text":68,"@type":64},"It asks whether someone besides the client provides answers; if another person answers, the form captures that person’s name and relationship and continues with household-care related questions accordingly.",{"name":70,"@type":61,"acceptedAnswer":71},"Which topics are covered under living situation, income, and assets?",{"text":72,"@type":64},"It records whether the home is public housing, the living arrangement with caregiver(s), monthly income and asset ranges (including refusal options), and needs related to food assistance, evacuation, and special needs registry enrollment.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},176935,1788326210,{"code":4,"msg":82,"data":83},"success",[84,89,94,99,104,109,113,118,123],{"id":85,"doc_module":22,"doc_module_name":25,"category_name":86,"show_sort_weight":87,"slug":88},11,"Presentations",90,"presentations",{"id":90,"doc_module":22,"doc_module_name":25,"category_name":91,"show_sort_weight":92,"slug":93},12,"Resumes",80,"resumes",{"id":95,"doc_module":22,"doc_module_name":25,"category_name":96,"show_sort_weight":97,"slug":98},14,"Invoices",70,"invoices",{"id":100,"doc_module":22,"doc_module_name":25,"category_name":101,"show_sort_weight":102,"slug":103},15,"Posters",60,"posters",{"id":105,"doc_module":22,"doc_module_name":25,"category_name":106,"show_sort_weight":107,"slug":108},16,"Social Media",50,"social-media",{"id":110,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":111,"slug":112},17,40,"forms",{"id":114,"doc_module":22,"doc_module_name":25,"category_name":115,"show_sort_weight":116,"slug":117},18,"Letters",30,"letters",{"id":119,"doc_module":22,"doc_module_name":25,"category_name":120,"show_sort_weight":121,"slug":122},21,"Paper Templates",5,"papers-templates",{"id":124,"doc_module":22,"doc_module_name":25,"category_name":125,"show_sort_weight":4,"slug":126},158,"General","general-158",{"code":4,"msg":82,"data":128},{"doc_id":79,"user_id":129,"nickname":42,"user_avatar":130,"doc_module":22,"category_id":110,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":136,"language":137,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":138,"faqs":139,"seo_title":140,"seo_description":12,"update_tm":80,"read_time":141},549768072016,"https://ap-avatar.wpscdn.com/davatar_155a257f0dc6eb9ab79c44ca47cae57d","\u0013 SHAPE  \\* MERGEFORMAT \u0014\nFlorida Department of Elder Affairs 701B Comprehensive Assessment\nRule: 58-A-1.010, F.A.C.\n\u0015\nAppendix XV\nProvider ID: \t\t\tProvider Assessor/CM ID:\nAssessor/Case\nManager (CM) Name: \t\tSignature:\nA. DEMOGRAPHIC SECTION\nASSESSOR/CM: What is the purpose of this assessment?\nInitial\t Annual\t Health\t Living situation\t Caregiver\t Environment\t Income\n2. Social Security number:\n3.  Name: a. First:\tb. Middle initial:\nc. Last:\n\u0013 SHAPE  \\* MERGEFORMAT \u0014\n4. Medicaid number:\n\u0015\n5.  Phone number:\n6.  Date of birth (mm/dd/yyyy):\n7.  Sex:\t Male\t Female\n10. Primary language:\t English\tSpanish\tOther:\n9.  Ethnicity:\t Hispanic/Latino\t Other\n11. Does client have limited ability reading, writing, speaking, or understanding English?   No   Yes\n\u0013 SHAPE  \\* MERGEFORMAT \u0014\n12. Marital status:\t Married\t Partnered\t Single\t Separated\t Divorced\t Widowed\n\u0015\na. Street:\n13. ASSESSOR/CM: Current Physical Location Address (If type is a facility, enter facility name.)\nb. City:\t\t c. ZIP code:\na. Street:\nb. City:\tc. ZIP code:\n15. Is client’s home address public housing? No Yes\n\u0013 SHAPE  \\* MERGEFORMAT \u0014\n16. Mailing Address (If different from current physical location)\n\u0015\nc. State:\td. ZIP code:\na. Street:\tb. City:\nDEMOGRAPHIC SECTION, CONTINUED\n22. ASSESSOR/CM: Imminent risk of nursing home placement?\t No\t Yes\n24. Are you enrolled on a special needs registry?\t No\t Yes\n23. Do you need outside assistance to evacuate?\t No\t Yes\nIs there a primary caregiver?\t No\t Yes\nLiving situation:   With primary caregiver\t With other caregiver\t With other\t Alone\nIndividual monthly income:\t $\t  Refused\nCouple monthly income:\t$\t Refused\t N/A\nEstimated total individual assets:  $\n $0 to $2,000\t $2,001 to $5,000\t $5,001 or more\t Refused\n32. Do you need other assistance for food?\t No\t Yes\n31. Are you receiving S/NAP (food stamps)?\t No\t Yes\nASSESSOR/CM: Is someone besides the client providing answers to questions?\t No (Skip to 34)  Yes\n\u0013 SHAPE  \\* MERGEFORMAT \u0014\na. Name: \t b.Relationship:\n\u0015\nBesides your own children, how many children under age 19 do you live with and provide care for?\n(if zero, skip to 35)\t#\nHow many are grandchildren?\t #\t  Name(s):\nHow many are other related children?\t#\tName(s):\nHow many are other non-related children?\t #\t  Name(s):\nHow many disabled adults age 19 to 59 do you live with and provide care for? (if zero, skip to 36)\t#\nHow many are grandchildren?\t #\t  Name(s):\nHow many are other relatives?\t#\tName(s):\nHow many are other non-relatives?\t #\t  Name(s):\nNotes & Summary:\nMEMORY SECTION\nGENERAL HEALTH, SENSORY & COMMUNICATION SECTION\nACTIVITIES OF DAILY LIVING SECTION\nNotes & Summary:\nINSTRUMENTAL ACTIVITIES OF DAILY LIVING SECTION\nNotes & Summary:\nHEALTH CONDITIONS & THERAPIES SECTION\nNotes & Summary:\nMENTAL HEALTH SECTION\nASSESSOR/CM: If the client is not answering questions, skip to Question 81 and check:\t\nHow satisfied are you with your overall quality of life?\t Very satisfied   Satisfied\nNeither satisfied nor dissatisfied\t Dissatisfied\t Very dissatisfied\nThinking about how you were this time last year, how do you feel about the way things are now?\nMuch better\t Better\t About the same\t Worse\t Much worse\n*Thoughts of suicide or self-injury, hallucinations, or aggressive behaviors are potentially serious problems that should be reported immediately to a supervisor, primary care physician, emergency care, law enforcement, and/or Adult Protective Services, as appropriate.\nASSESSOR/CM: If the client answered “Not at all” to a-i above, skip to Question 81.\nHow difficult have these problems made it for you in your daily life activities and interactions with others?\nNot difficult at all\t Somewhat difficult\t Very difficult\t Extremely difficult\nAre you currently working with a professional to help with this condition?  No\t Yes (Skip to 81)\nHave you or do you plan to discuss these issues with a professional?\t No\t Yes (Skip to 81)\nDo you talk about any of these issues with anyone else you know?\t","cbCaibHTIQQBfcji","https://ap.wps.com/l/cbCaibHTIQQBfcji","docx",109956,19,"English","# ASSESSOR/CM Purpose of Assessment\n# Client Demographic Information\n## Identifiers and Contact\n## Language, Reading Ability, Sex, Ethnicity\n# Marital Status and Addresses\n## Current Physical Location Address\n## Mailing Address\n# Living Situation and Housing\n## Public Housing Status\n## Living Arrangement and Caregiver\n# Income, Assets, and Assistance Needs\n## Income and Asset Ranges\n## S/NAP and Food Assistance\n## Special Needs Registry and Evacuation Assistance\n# Family Composition and Care Needs\n## Children and Care for Minors\n## Disabled Adults in Household\n## Notes & Summary","[{\"question\":\"What information is collected in the Demographic Section of the 701B assessment?\",\"answer\":\"The section collects client identifiers, contact details, language and reading ability, sex, ethnicity, marital status, addresses, and relevant living situation details needed for assessment planning.\"},{\"question\":\"How does the form address response assistance from someone other than the client?\",\"answer\":\"It asks whether someone besides the client provides answers; if another person answers, the form captures that person’s name and relationship and continues with household-care related questions accordingly.\"},{\"question\":\"Which topics are covered under living situation, income, and assets?\",\"answer\":\"It records whether the home is public housing, the living arrangement with caregiver(s), monthly income and asset ranges (including refusal options), and needs related to food assistance, evacuation, and special needs registry enrollment.\"}]","A. DEMOGRAPHIC SECTION | DOCX",7]