NAT - 10-1-21 - Needs Assessment Tool - Individual Identification and Assessment Information

Sep 12, 2026

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Needs Assessment Tool (NAT) form NAT 10-1-21 for face-to-face interviews, collecting structured information about an individual’s identification, assessment context, participation, and authorization status. It includes demographic and identity fields such as name, birth date, gender identity, sex assigned at birth, sexual orientation, ethnicity, race, and insurance indicators (Medicaid/Medicare/other). The form also captures needs assessment tool type, interview location, related-participant details, legal guardianship and power of attorney information, and homelessness and permanent living arrangements.

LanguageEnglish

CategoryForms

FormatPDF

Pages34

Reading Time12 min

AccessFree to download

1. Introduction

1.A. Individual's Identification

1.B. Assessment Information

1.C. Power of Attorney (POA) / Legal Guardianship

1.D. Individual's Demographics

NAT 10-1-21 | 1. INTRODUCTION | | --- | | 1.A. INDIVIDUAL'S IDENTIFICATION | 1. Date of the face to face interview for Needs Assessment Tool (NAT) 2. Individual's Last Name 3. Individual's First Name 4. Individual's Middle Initial 5. Individual's Name Suffix (If applicable) 6. Individual's Nickname/ Alias 7. Individual's Date of Birth (DOB) 8a. Individual's current gender identity (defined as one's inner sense of one's own gender) (Select one) Female Male Non-Binary Transgender Female (male to female) Transgender Male (female to male) Something else that was not named. Please specify (Document Details in Notes) Choose not to disclose 8b. Individual's sex assigned on their birth certificate at birth (Select one) Female Male Something else that was not named. Please specify (Document Details in Notes) Choose not to disclose 8c. Individual’s sexual orientation (defined as one’s identification of emotional, romantic, sexual, or affectional attraction to another person) (Select one) Bisexual Lesbian, Gay or Homosexual Straight or Heterosexual Something else that was not named. Please specify (Document Details in Notes) Don’t know Choose not to disclose 9. Individual's Ethnicity Hispanic or Latino Not Hispanic or Latino 10. Individual's Race American Indian/ Native Alaskan Asian Black/ African American Native Hawaiian/ Other Pacific Islander Non-Minority (White, non-Hispanic) White-Hispanic Unknown/ Unavailable Other-Document Details in Notes 11. Individual's Social Security Number (SSN) 12a. Does the individual have a Medicaid number? No Yes Pending 12b. Indicate Medicaid recipient number 13a. Does the individual have Medicare? | 13b. Indicate Medicare recipient number | | | --- | --- | | 14a. Does the individual have any other insurance? | | | | No Yes
Don't know | 14b. Indicate other health insurance information 1. B. ASSESSMENT INFORMATION NAT 10-1-21 1. PSA number conducting assessment: 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 2. Indicate type of Needs Assessment Tool (NAT) Annual Care Plan DC-Domiciliary Care Annual Initial Significant Change in Needs Other-Document Details in Notes | 3. Where was the individual interviewed?
AL-Assisted Living DC-Domiciliary Care Home
Home of Relative/ Caregiver Hospital
PCH-Personal Care Home
Other-Document Details in Notes | | --- | | 4. Did the individual participate in the assessment?
No-Must complete 1. B.5
Yes | 5. If anyone else participated during the time of the needs assessment, please document the name and relationship in Notes. 1-Spouse/ Domestic Partner 2-Family-Other than Spouse 3-Legal Guardian 4-Durable Power of Attorney (POA) 5-Friend 6-Other-Document Name and Relationship in Notes 1.C. POWER OF ATTORNEY (POA) / LEGAL GUARDIANSHIP 1a. Does the individual have a legal guardian? No-Skip to 1.C.2a Yes | 1b. Was proof of legal guardianship provided? | | | --- | --- | | | No Yes | | 1c. Name of legal guardian | | | 1d. Complete address of legal guardian | | | 1e. Primary phone number of legal guardian | | | 1f. Secondary phone number of legal guardian | | | 1g. E-mail address of legal guardian | | NAT 10-1-21 Page 2 of 34 2a. Does the individual have a Power of Attorney (POA)? No-Skip to 1.D.1a Yes 2b. Proof of POA provided? | 2c. Type of POA | | | --- | --- | | | Durable Financial Health
Other-Document Details in Notes | | 2d. Name of POA | | | 2e. Complete address of POA | | | 2f. Primary phone number of POA | | | 2g. Secondary phone number of POA | | 2h. E-mail address of POA 1. D. INDIVIDUAL'S DEMOGRAPHICS 1a. Is the individ

FAQs

What information is collected in the NAT form’s Individual’s Identification section?

It collects the interview date and the individual’s name details, nickname/alias, date of birth, gender identity, sex assigned at birth, sexual orientation, ethnicity, race, and relevant identification notes.

How does the NAT capture the needs assessment context and interview participation?

It records the PSA number conducting the assessment, the NAT type, the interview location, whether the individual participated, and any additional participants’ names and relationships in the notes.

What legal and living situation data does the NAT request?

It asks whether the individual has a legal guardian or a Power of Attorney (POA), evidence provided status, and POA/guardian contact details. It also gathers homelessness status and the type of permanent residence and living arrangement.

Sep 12, 2026

Upload by Tawan