Get 3122 Form

The 3122 Form is an essential document required for the admission process into an Assisted Living Residence. Completing this form accurately ensures that the individual receives appropriate care tailored to their needs. This guide will assist you in filling out the form online efficiently.

Follow the steps to complete the 3122 Form with ease.

1. Click the ‘Get Form’ button to obtain the form and open it in the online editing environment.
2. Begin by filling in the top of the first page where you will write the resident’s name, the name of the facility, and the date of the evaluation.
3. Indicate the purpose of the evaluation by checking the appropriate box among pre-admission, annual review, 6-month review of ISP, or change in physical/functional status.
4. Complete Section I: Personal Data by providing general information such as date of birth, gender, social security number, marital status, emergency contact details, attending physician, health insurance information, and pharmacy details.
5. In Section 2: Personal Background, provide detailed family, social, educational, and residential background information. Ensure to include the preferred name for addressing the resident.
6. Proceed to Section 3: Customary Routine where you will record the resident's preferences in sleep, bathing, and eating habits based on discussions with the resident or their family.
7. In Section 4: Continence Status/Management, check the appropriate boxes regarding the resident’s bowel and bladder continence status. Provide details if any incontinence management techniques are used.
8. Fill out Section 5: Physical Function by assessing the resident's ability to perform Activities of Daily Living (ADLs) and instrumental activities of daily living (IADLs). Include comments that highlight important details.
9. Complete Section 6: Cognitive Impairment Screen to evaluate the resident’s cognitive abilities. Note any observed behaviors and overall cognitive functioning.
10. Finalize by filling out Section 7: Admission / Level of Care where you indicate the resident’s current level of care and necessary signatures from appropriate staff and the resident.
11. After filling out all sections, save your changes and select your preferred option to download, print, or share the completed form online.

Start filling out the 3122 Form online today to ensure a seamless admission process.