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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.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/nat-10-1-21-needs-assessment-tool-individual-identification-and-assessment-information/246974/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/nat-10-1-21-needs-assessment-tool-individual-identification-and-assessment-information/246974.png","ImageObject",442,249,{"name":88,"@type":89},"Tawan","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-23","2026-09-12",true,{"@type":98,"interactionType":99,"userInteractionCount":47},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What information is collected in the NAT form’s Individual’s Identification section?","Question",{"text":108,"@type":109},"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.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"How does the NAT capture the needs assessment context and interview participation?",{"text":113,"@type":109},"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.",{"name":115,"@type":106,"acceptedAnswer":116},"What legal and living situation data does the NAT request?",{"text":117,"@type":109},"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.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},246974,1790626524,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":47,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":135,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":15},2336475104042,"https://ap-avatar.wpscdn.com/avatar/22000c4c32af1715be0?x-image-process=image/resize,m_fixed,w_180,h_180&k=1786537525561427321","NAT 10-1-21  \n\n| 1. INTRODUCTION |\n| --- |\n| 1.A. INDIVIDUAL'S IDENTIFICATION |\n\n1. Date of the face to face interview for Needs Assessment Tool (NAT)  \n2. Individual's Last Name  \n3. Individual's First Name  \n4. Individual's Middle Initial  \n5. Individual's Name Suffix (If applicable)  \n6. Individual's Nickname/ Alias  \n7. Individual's Date of Birth (DOB)  \n8a. Individual's current gender identity (defined as one's inner sense of one's own gender) (Select one)  \nFemale Male Non-Binary  \nTransgender Female (male to female)  \nTransgender Male (female to male)  \nSomething else that was not named. Please specify (Document Details in Notes)  \nChoose not to disclose  \n8b. Individual's sex assigned on their birth certificate at birth (Select one)  \nFemale Male  \nSomething else that was not named. Please specify (Document Details in Notes)  \nChoose not to disclose  \n8c. Individual’s sexual orientation (defined as one’s identification of emotional, romantic, sexual, or affectional attraction to another person) (Select one)  \nBisexual  \nLesbian, Gay or Homosexual Straight or Heterosexual  \nSomething else that was not named. Please specify (Document Details in Notes)  \nDon’t know  \nChoose not to disclose  \n9. Individual's Ethnicity  \nHispanic or Latino Not Hispanic or Latino  \n10. Individual's Race  \nAmerican Indian/ Native Alaskan Asian  \nBlack/ African American  \nNative Hawaiian/ Other Pacific Islander Non-Minority (White, non-Hispanic) White-Hispanic  \nUnknown/ Unavailable  \nOther-Document Details in Notes  \n11. Individual's Social Security Number (SSN)  \n12a. Does the individual have a Medicaid number?  \nNo  \nYes  \nPending  \n12b. Indicate Medicaid recipient number  \n13a. Does the individual have Medicare?  \n| 13b. Indicate Medicare recipient number |  |\n| --- | --- |\n| 14a. Does the individual have any other insurance? |  |\n| | No Yes\u003Cbr>Don't know |\n\n14b. Indicate other health insurance information  \n1. B. ASSESSMENT INFORMATION  \nNAT 10-1-21  \n1. PSA number conducting assessment:  \n 01  \n 02  \n 03  \n 04  \n 05  \n 06  \n 07  \n 08  \n 09  \n 10  \n 11  \n 12  \n 13  \n 14  \n 15  \n 16  \n 17  \n 18  \n 19  \n 20  \n 21  \n 22  \n 23  \n 24  \n 25  \n 26  \n 27  \n 28  \n 29  \n 30  \n 31  \n 32  \n 33  \n 34  \n 35  \n 36  \n 37  \n 38  \n 39  \n 40  \n 41  \n 42  \n 43  \n 44  \n 45  \n 46  \n 47  \n 48  \n 49  \n 50  \n 51  \n 52  \n2. Indicate type of Needs Assessment Tool (NAT)  \n Annual Care Plan  \n DC-Domiciliary Care Annual  Initial  \n Significant Change in Needs  Other-Document Details in Notes  \n\n| 3. Where was the individual interviewed?\u003Cbr> AL-Assisted Living  DC-Domiciliary Care  Home\u003Cbr> Home of Relative/ Caregiver  Hospital\u003Cbr> PCH-Personal Care Home\u003Cbr> Other-Document Details in Notes |\n| --- |\n| 4. Did the individual participate in the assessment?\u003Cbr> No-Must complete 1. B.5\u003Cbr> Yes |\n\n5. If anyone else participated during the time of the needs assessment, please document the name and relationship in Notes.  \n1-Spouse/ Domestic Partner  \n2-Family-Other than Spouse  \n3-Legal Guardian  \n4-Durable Power of Attorney (POA)  \n5-Friend  \n6-Other-Document Name and Relationship in Notes  \n1.C. POWER OF ATTORNEY (POA) / LEGAL GUARDIANSHIP  \n1a. Does the individual have a legal guardian?  \nNo-Skip to 1.C.2a  \nYes  \n\n| 1b. Was proof of legal guardianship provided? |  |\n| --- | --- |\n| | No Yes |\n| 1c. Name of legal guardian |  |\n| 1d. Complete address of legal guardian |  |\n| 1e. Primary phone number of legal guardian |  |\n| 1f. Secondary phone number of legal guardian |  |\n| 1g. E-mail address of legal guardian |  |\n\nNAT 10-1-21  \nPage 2 of 34  \n2a. Does the individual have a Power of Attorney (POA)?  \nNo-Skip to 1.D.1a  \nYes  \n2b. Proof of POA provided?  \n| 2c. Type of POA |  |\n| --- | --- |\n| | Durable Financial Health\u003Cbr>Other-Document Details in Notes |\n| 2d. Name of POA |  |\n| 2e. Complete address of POA |  |\n| 2f. Primary phone number of POA |  |\n| 2g. Secondary phone number of POA |  |\n\n2h. E-mail address of POA  \n1. D. INDIVIDUAL'S DEMOGRAPHICS  \n1a. Is the individ","cbCaivIOgaoBvtBN","https://ap.wps.com/l/cbCaivIOgaoBvtBN","pdf",1564914,34,"English","# 1. Introduction\n## 1.A. Individual's Identification\n## 1.B. Assessment Information\n## 1.C. Power of Attorney (POA) / Legal Guardianship\n## 1.D. Individual's Demographics","[{\"question\":\"What information is collected in the NAT form’s Individual’s Identification section?\",\"answer\":\"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.\"},{\"question\":\"How does the NAT capture the needs assessment context and interview participation?\",\"answer\":\"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.\"},{\"question\":\"What legal and living situation data does the NAT request?\",\"answer\":\"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.\"}]","NAT - 10-1-21 - Needs Assessment Tool - Individual Identification and Assessment Information | PDF",1789239256]