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b. DESCRIBE ANY CHRONIC MEDICAL PROBLEMS A CAREGIVER SHOULD BE AWARE OF DA FORM 5189 SEP 2002 EDITION OF JUL 1993 IS OBSOLETE USAPA V1.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....
Open form follow the instructions
Easily sign the form with your finger
Send filled & signed form or save
How to fill out the Da Form 5189 online
Filling out the Da Form 5189 is essential for requesting respite care for individuals with disabilities. This guide will walk you through the process of completing the form online with clarity and ease.
Follow the steps to fill out the form accurately and efficiently.
- Use the ‘Get Form’ button to access and open the form in your preferred editor.
- In Section A, provide the name of the person with a disability as well as their birthdate in the YYYYMMDD format. Include the name of the parent, guardian, or responsible family member along with their address and telephone numbers.
- List an emergency contact, including their name, address, and telephone number. If this person is unavailable, name an alternative who will accept responsibility.
- Detail other household members by listing their names and birthdates in YYYYMMDD format.
- Provide the name and contact information for the individual's physician and dentist, as well as the preferred hospital.
- Indicate the regular program attended by the individual, such as school or sheltered work.
- In the descriptive information section, outline the individual’s disability, chronic medical issues, and allergies the caregiver should know about.
- Describe any history of seizures, including their type and frequency, and specify any special equipment used by the individual.
- Record the individual's height and weight, and indicate their capabilities in various activities like toileting and walking.
- In Section B, list any medications the individual takes regularly and their purposes. Provide special instructions regarding medical conditions and bodily functions.
- After completing the form, save your changes. You may choose to download, print, or share the finalized form as needed.
Complete the Da Form 5189 online today to ensure the necessary care for your loved one.
Experience a faster way to fill out and sign forms on the web. Access the most extensive library of templates available.
Related content
Oct 30, 2020 — About VA Form 21-8951-2. Form name: Notice of Waiver of VA Compensation...
Nov 22, 2006 — Completion of DD Form 2792 (Exceptional Family Member Medical ... for the...
Mail your letter or DA Form 2028 (Recommended Changes to Publications and...
Get answers to your most pressing questions about US Legal Forms API.
How to fill out the application form?
To fill out the application form properly, such as Da Form 5189, begin by accessing the form on the US Legal Forms platform. This service not only provides the form but also offers helpful guidelines for each section. Follow the prompts closely, ensuring that you provide all necessary details. Finally, double-check your work to ensure everything is filled out correctly before submission.
How do I fill out an application form?
Filling out an application form like Da Form 5189 is straightforward. Start by downloading the form from the US Legal Forms website, where you can access it easily. Carefully enter your information in the designated fields, ensuring accuracy and clarity. After completing Da Form 5189, remember to review it thoroughly before submitting it as required.
How to fill out an application online?
To fill out an application online using Da Form 5189, visit the US Legal Forms website. There, you will find a user-friendly interface guiding you through each step of the application. Simply select Da Form 5189 from the list of available forms, and follow the on-screen instructions to enter your information. Once you complete the form, you can save and submit it directly through the platform.
Can you ask a Soldier for their profile?
Yes, you can ask a soldier for their profile to understand their medical restrictions and capabilities. It is essential for ensuring that assignments are suitable and safe. Clear communication about a soldier's profile contributes to effective unit coordination. Using forms like the Da Form 5189 can help formalize this request for better clarity and documentation.
How long is a DA form 3749 good for?
A DA Form 3749, which pertains to equipment and property management, remains valid for the duration specified by the officer managing the property. Typically, these forms do not have a strict expiration date, but they should be updated as circumstances change. Keeping your documentation current is critical for compliance and organization. Utilizing resources like US Legal Forms can help you track and manage these forms effectively.
What is a DA form 2062 used for?
DA Form 2062 is used for hand receipts and inventories of property within the military. This form ensures a clear record of property transfers and accountability among units. It plays a vital role in maintaining oversight and organization regarding Army equipment and supplies. For quick access to this form, consider using the US Legal Forms platform.
What is DA form 3349 used for?
DA Form 3349 is used to communicate a soldier's medical and physical profile to leadership and healthcare providers. This form guarantees that soldiers receive appropriate assignments based on their fitness level. Moreover, it facilitates necessary accommodations for soldiers with various medical conditions. Accessing the DA Form 3349 through US Legal Forms streamlines this process.
What is a DA 3349?
A DA 3349 is a document designed for recording a soldier's medical profile and any related restrictions. It is essential for determining a soldier's physical abilities and corresponding duties. Having a well-documented profile helps ensure that each soldier operates within their capacity, promoting safety and effectiveness. You can easily find this form on platforms like US Legal Forms.
What DA form is used to record profiles?
The DA Form used to record profiles is DA Form 3349. This form captures information about a soldier's medical profile and is crucial for ongoing medical evaluations. Using DA Form 3349 ensures that all soldiers' medical needs are documented accurately, which ultimately supports their wellness. Resources such as US Legal Forms can assist you in accessing this form.
What is a P3 or P4 profile?
A P3 or P4 profile indicates a soldier's physical limitations and operational capabilities. Specifically, P3 refers to soldiers who can perform duties but require some restrictions, while P4 designates those who have more significant limitations. Understanding these profiles helps in managing personnel readiness. Proper documentation like the Da Form 5189 can be instrumental in this process.
Use professional pre-built templates to fill in and sign documents online faster. Get access to thousands of forms.
If you believe that this page should be taken down, please follow our DMCA take down process here.