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It collects person information, admission details, living arrangements, emergency contacts, and health care provider information. The document includes service agreement terms covering supervision, medication administration, assistance with daily living, hygiene oversight, therapy monitored exercise, and meals/snacks. 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At a minimum, you must fill in the blanks on this form. You may modify the format and content to meet standards used by your program. This sample meets compliance with current licensing requirements as of October 1, 2017. Providers remain responsible for reading, understanding and ensuring that this document conforms to current licensing requirements. DELETE THIS HIGHLIGHTED SECTION TO BEGIN MODIFYING THIS FORM.\nParticipant Application\nPerson Information\nAdmission Information\nLiving Arrangement\nEmergency contact information #1\nEmergency contact information #2\nHealth care provider contact information\nService Agreement\n[Program Name] agrees to provide supervision, administration of medications, assistance with activities of daily living, supervision of personal hygiene, supervised recreational and social activities, a therapy monitored exercise program, and meals and snacks provided by nutrition services as appropriate to the\nlength of time spent at program each day.\nParticipant and/or Responsible Party agrees to:\nPay the amount listed below for each day of services. Meals and snacks are included in this amount.\n( [Insert rate here]\t( [Insert rate here]\t( [Insert rate here]\nPay the additional amount listed below for transportation services (if applicable).\n( [Insert rate here]\nProvide clothing, undergarments, and continence products as needed or desired by the participant.\nProvide spending money as needed or desired by the participant.\nProvide medications prescribed by the participant’s physician in a pharmacy labeled bottled.\nIntake Screening:\nDate of intake screening:______________________\nNames of persons that were interviewed for intake screening:__________________________________\nDate individual was provided notification of outcome of intake screening (within five working days of screening):_________________\nIs participant capable of self-preservation?\t( Yes\t\t( No\nParticipant’s Rights & Right to Contest\nPerson name:\nProgram name:\n(  I received a copy of the center's statement on participants' rights.\nWhen receiving services and supports from this program name, I have the right to:\nthe right to participate in developing one's own plan of care;\nthe right to refuse care or participation;\nthe right to physical privacy during care or treatment;\nthe right to confidentiality of participant records; and\nthe right to present grievances regarding treatment or care in accordance with part \u0013 HYPERLINK \"https://www.revisor.mn.gov/rules/?id=9555.9640\" \u00149555.9640\u0015, item D.\n(  The center provided me with written notice ensuring that myself or my guardian/caregiver has been informed of my right to contest the accuracy and completeness of the data maintained in my record.\nDate of admission:  \t\t\t\t Date I received this information:\nPolicy Orientation Acknowledgement\nOrientation to the following policies was received within 24 hours of admission, or 72 hours for persons who would benefit from a later orientation:\nMaltreatment of Vulnerable Adults\nProgram Abuse Prevention Plan\nDate of admission:  \t\t\t\t Date I received this information:\nI received written information on the following:\nthe scope of the programs, services, and care offered by the center;\n§a description of the population to be served by the center;\na description of individual conditions which the center is not prepared to accept, such as a communicable disease requiring isolation, a history of violence to self or others, unmanageable incontinence or uncontrollable wandering;\nthe participants' rights developed in accordance with part \u0013 HYPERLINK \"https://www.revisor.mn.gov/rules/?id=9555.9670\" \u00149555.9670\u0015 and additionally:\na procedure for presenting grievances, including the name, address, and telephone number of the licensing division of the department, to which a participant or participant's caregiver may submit an or","cbCaigiNvodF9vVZ","https://ap.wps.com/l/cbCaigiNvodF9vVZ","docx",60957,"English","# Person Information\n# Admission Information\n# Living Arrangement\n# Emergency Contact Information\n## Emergency contact information #1\n## Emergency contact information #2\n# Health Care Provider Contact Information\n# Service Agreement\n# Intake Screening\n# Participant’s Rights & Right to Contest\n# Policy Orientation Acknowledgement\n# Needs Assessment","[{\"question\":\"What information does the form collect during participant application?\",\"answer\":\"The form collects person information, admission information, living arrangement details, emergency contact information (two entries), and health care provider contact information.\"},{\"question\":\"What does the service agreement cover?\",\"answer\":\"It covers supervision, administration of medications, assistance with activities of daily living, supervision of personal hygiene, supervised recreational and social activities, a therapy monitored exercise program, and meals and snacks as appropriate.\"},{\"question\":\"When must the needs assessment be completed and documented?\",\"answer\":\"The needs assessment must be completed within 30 days of admission and placed in the participant’s record.\"}]","Participant Record - Adult Day Services Application | DOCX",6]