Submitted by Applicant Other (indicate whom)________________
Bergen County Division of Senior Services Aging & Disability Resource Connection MEALS ON WHEELS APPLICATION Fax 201-336-7424 Tele. 201-336-7420 Date of application
Applicant has agreed to accept MOW Discharged from hospital/rehab within 30 days There may be a wait list for MOW. Is someone able to assist you while you are waiting for MOW? Yes- limited assistance No support system
___________ /_______________ / 2017
Applicant language: If non-English speaking indicate language spoken Homebound Status Unable to leave home without assistance
Living Arrangement (select all that apply) Live alone
Female Head of Household
Able to leave home independently
With spouse/ domestic partner /civil union
Reason applying for MOW-
With roommate/friend/family or other informal caregiver
Diet: Regular/Heart Healthy/ No added salt Special diets are not available
Caregiver is not home during the day Caregiver is home during the day Applicant is caring for a disabled child
Last Name
First Name
Address
Apt/Floor
Date of Birth (mm/dd/yy)
Age
Front door Back door Side door Ring Bell Knock Driver has key to door Hard-of-hearing Visually impaired Oxygen user Non-ambulatory Wheelchair user Dementia Walker/cane user Other
Ethnicity (select one)
Not Hispanic/Latino Hispanic/Latino Sex/Gender Female Male
Transgender
Intersex
Other
Do you receive Medicaid? Yes No Do you receive Managed Long Term Support Services (MLTSS) Yes No
Nick Name or Preferred Name
City
Telephone Number Home ( ) Mobile (
Driver Instructions (check all that apply)
MI
Do you have a home health aide? Yes No Number of hours of daytime care: ____________
Primary
)
Directions to home (include cross st; access code to bldg,etc.)
Race (select one or more; information collected for federal statistics) American Indian/ Alaskan Native Asian Black/African American Pacific Islander/Native Hawaiian White Other
Frail
Sexual Orientation (optional): Heterosexual/Straight Lesbian/Gay Bisexual Unsure If not listed above, please specify.
Veteran of US Armed Service
Income (select one) $1005. month or below (1-person household) $1353. month or below (2-person household) Emergency Contact Information: Name
$1006. month or above (1-person household)
Relationship
Authorize to discuss case with this contact Physician Name Town
Authorize to discuss case with this contact
Unknown
Telephone Number indicates primary Home
Mobile
Authorize to discuss case with this contact
Town
Yes No
$1354. month or above (2-person household)
Town Name
Vulnerable
Relationship
Business
Home Mobile Business
Business
The WELLNESS CHECK PROGRAM is an automated telephone reassurance program designed to check on the well-being of residents who live alone, are homebound, and over the age of 60, or age 18+ with a disability. Meals on Wheels participants are encouraged to enroll in this program. Check if you DECLINE to be enrolled or receive information about the Wellness Check Program.
INSTRUMENTAL ACTVITIES OF DAILY LIVING In the last 7-days, if you’ve had some difficulty in performing any of the following tasks by yourself, or required personal or standby assistance, or supervision, check ‘impairment’.
1. 2. 3. 4.
Preparing Meals ……………………. Laundry/Ordinary Housework.. Heavy Housework ………………… Shopping ………………………………
Impairment Impairment Impairment Impairment
5. Managing Medicine……………….. Impairment 6. Using Transportation……………. Impairment 7. Paying Bills/Managing Money... Impairment 8. Using the Telephone………………. Impairment
ACTIVITIES OF DAILY LIVING In the last 7-days, if you’ve had difficulty or required any help in performing the following, check ‘impairment’.
1. Bathing……. Impairment 2. Dressing……. Impairment 3. Eating…….. Impairment
4. Getting out of the bed or chair… Impairment 5. Walking ………………………………….. Impairment 6. Toileting ………………………………… Impairment
NUTRITION SCREENING The warning signs of poor nutritional health are often overlooked. This survey will help identify if you are at nutritional risk. Read the statements below. Check the appropriate column. 1. 2. 3. 4. 5. 6. 7.
Do you eat fewer than 2 meals a day? …………………………………………………………….……… Do you eat alone most of the time? ……………………………………………………………………….. Do you eat fewer than 2 servings of milk or milk products a day?.............................. Do you eat fewer than 5 servings of fruits and/or vegetables a day?.......................... Do you have 3 or more drinks of beer, liquor, or wine almost every day?................... Without wanting to, have you lost or gained weight in the last 6 months?................. Do you have an illness or health condition that made you change the kind or amount of food that you eat? (Ex: Diabetes, Heart Disease, Kidney Disease, etc.) …………… 8. Do you take 3 or more prescribed or over the counter drugs a day?........................... 9. Are you unable to physically shop, cook, and/or feed yourself, or get someone to do it for you?.......................................................................................................... 10. Do you have a problem with your teeth or mouth that makes it hard to eat?............
11. Do you sometimes run out of money to buy food?.....................................................
No No No
Yes Yes Yes
No No
Yes Yes
No
Yes, lost
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
Yes, gained
If you wish to speak with a dietitian regarding your nutritional health, please check this box.
Preferred Meal Plan (select one): Hot: One hot meal delivered each weekday Monday-Friday. Frozen: One week supply of 7-frozen meals delivered on a scheduled day each week. High risk clients only / Weekday delivery of 2-frozen meals for use on the weekend.
Frozen meals are fully cooked and can be reheated in a conventional or microwave oven.
INDIVIDUAL RESPONSIBILITY You must be home to accept your meal delivery and make contact with the driver. Your driver can not leave your meal without knowing that you are safe. Drivers must have safe access to your door including but not limited to proper restraint or confinement of all pets during delivery. If you have a doctors’ appointment or will not be home, you must temporarily suspend your meal delivery by calling Meals on Wheels no later than 12:00 noon the business day before. You can leave a message any time of the day, 7-days a week. If you do not hear the door and find an ‘Attempted to Deliver’ tag left by the driver, or receive a voice message, call Meals on Wheels immediately at 201-336-7420. If we do not hear from you, we will stop your meal delivery and may call the police to check on your well-being. Repeated failure to suspend your delivery or late suspension may result in termination from the program. Food is a valuable resource that we cannot waste. A voluntary donation of $1.25 per meal is suggested. Please donate whatever you are able. We can only provide one meal a day, and we may not be able to deliver that meal as planned on any given day due to hazardous weather conditions or other unforeseen circumstances. You must keep food in your home at all times. Every 6-month a face-to-face assessment in your home is required to determine your eligibility to continue to receive home delivered meals and to provide possible referrals for other services to benefit you. A representative will contact you to schedule an appointment within a four--hour window. A family member or caregiver can be present if you wish.
By submission of this application, I certify that the information provided for my eligibility determination is correct to the best of my knowledge, and I understand and agree to the client responsibilities when accepting this service. Signature
____________________________________________________________________
Date_____________________________