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DESCRIPTIVE INFORMATION Individual with Disability a. DESCRIBE INDIVIDUAL S DISABILITY b. DESCRIBE ANY CHRONIC MEDICAL PROBLEMS A CAREGIVER SHOULD BE AWARE OF DA FORM 5189 SEP 2002 EDITION OF JUL 1993 IS OBSOLETE USAPA V1. APPLICATION FOR RESPITE CARE FOR CHILDREN AND ADULTS WITH DISABILITIES For use of this form see AR 608-75 the proponent agency is OACSIM AUTHORITY PRINCIPAL PURPOSE ROUTINE USES DISCLOSURE DATA REQUIRED BY THE PRIVACY ACT OF 1974 Title 5 United States Code Section 301. To identify specific disability of individual requiring respite care. needed* Providing information is voluntary. Failure to provide information will result in disapproval of prospective respite care user s application* SECTION A - IDENTIFYING AND RESOURCE INFORMATION 1. NAME Person with disability 3. BIRTHDATE YYYYMMDD 2. NAME Parent guardian or responsible family member 4. ADDRESS Include ZIP Code 5. TELEPHONE NUMBERS HOME MOTHER work FATHER work 6. EMERGENCY CONTACT Relative friend etc* Name address and telephone number IF THIS EMERGENCY CONTACT IS NOT AVAILABLE TO SUBSTITUTE FOR THE CAREGIVER IN AN EMERGENCY PLEASE GIVE THE NAME ADDRESS AND TELEPHONE NUMBER OF A PERSON WHO HAS AGREED TO BE AVAILABLE AND TO ACCEPT RESPONSIBILITY FOR THE PERSON WITH A DISABILITY IN THE EVENT YOU CANNOT BE REACHED. 7. LIST OTHER HOUSEHOLD MEMBERS a* NAME b. BIRTHDATE YYYYMMDD 8. PHYSICIAN Name address and telephone no. 9. DENTIST Name address and telephone no. 10. PREFERRED HOSPITAL Name and address 11. REGULAR PROGRAM ATTENDED BY INDIVIDUAL School sheltered work etc* 12. 00 c* LIST ANY ALLERGIES d. IS THERE A HISTORY OF SEIZURES If yes what kind and how often e. DESCRIBE ANY SPECIAL EQUIPMENT THE INDIVIDUAL USES Braces wheelchair etc* f* INDIVIDUAL S HEIGHT g. WEIGHT h. INDICATE THE EXTENT TO WHICH THE INDIVIDUAL CAN DO ANY OF THE FOLLOWING USE TOILET STAND TRANSFER INDEPENDENTLY WALK TALK FEED SELF CLIMB STAIRS BATHE SELF DRINK FROM A GLASS SIT UP ALONE DRESS SELF UNDERSTAND WORDS SECTION B - INSTRUCTIONS FOR CARE AND/OR SUPERVISION 1. LIST ANY MEDICATION GIVEN REGULARLY AND THE PURPOSE FOR WHICH IT IS USED 2. DESCRIBE SPECIAL INSTRUCTIONS FOR HANDLING SPECIFIC MEDICAL CONDITIONS Seizures allergies etc*. APPLICATION FOR RESPITE CARE FOR CHILDREN AND ADULTS WITH DISABILITIES For use of this form see AR 608-75 the proponent agency is OACSIM AUTHORITY PRINCIPAL PURPOSE ROUTINE USES DISCLOSURE DATA REQUIRED BY THE PRIVACY ACT OF 1974 Title 5 United States Code Section 301. To identify specific disability of individual requiring respite care. needed* Providing information is voluntary. To identify specific disability of individual requiring respite care. needed* Providing information is voluntary. Failure to provide information will result in disapproval of prospective respite care user s application* SECTION A - IDENTIFYING AND RESOURCE INFORMATION 1. Failure to provide information will result in disapproval of prospective respite care user s application* SECTION A - IDENTIFYING AND RESOURCE INFORMATION 1. NAME Person with disability 3. BIRTHDATE YYYYMMDD 2. NAME Parent guardian or responsible family member 4.

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Keywords relevant to Da Form 5189

  • toileting
  • OACSIM
  • 1993
  • proponent
  • disabilities
  • CAREGIVER
  • descriptive
  • Sep
  • respite
  • Disapproval
  • mobility
  • independently
  • disclosure
  • sheltered
  • requiring
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