Get Motorized Wheelchair Evaulation Form (pdf) - Hfs Illinois

This guide provides you with clear instructions on how to complete the Motorized Wheelchair Evaluation Form (pdf) - Hfs Illinois online. Following these steps will ensure that the necessary information is accurately submitted to facilitate the evaluation process.

Follow the steps to effectively complete the Motorized Wheelchair Evaluation Form.

1. Click the ‘Get Form’ button to access the form and open it in your preferred PDF editor.
2. Begin with the first section by entering the resident's name and the Recipient Identification Number (RIN). This information is essential for the identification of the individual for whom the evaluation is being conducted.
3. Next, specify the nursing facility name where the resident is located. This provides context for the evaluation and ensures proper routing of the form.
4. Proceed to question 1. Answer 'Yes' or 'No' to indicate whether the person has a physical limitation that prevents them from accomplishing a mobility-related activity of daily living. If the answer is 'No', you may stop here.
5. If the answer to question 1 is 'Yes', move to question 2. Here, indicate whether the person is unable to perform any of the listed activities, such as walking or propelling a manual wheelchair unassisted. Again, if the answer is 'No', you may stop here.
6. In questions 3a and 3b, assess if the person has the mental capacity sufficient for safe performance of mobility-related functions and whether they could be trained for safe operation of a motorized wheelchair. If the answer to both is 'No', stop here.
7. If the answers to questions 3a and 3b are 'Yes', continue to question 4, where you will indicate whether the person has the physical capabilities for the safe performance of a motorized wheelchair. If 'No', you may stop here.
8. Finally, answer question 5 to indicate whether the person would consent to a full evaluation for a motorized wheelchair.
9. Complete the form by entering the name and title/position of the person completing the form. This is significant for accountability.
10. Sign and date the declaration at the end of the form, certifying that the evaluation information contained herein is true and correct.
11. Once you have filled in all required fields, you can save your changes, download the completed form, print it for submission, or share it with relevant parties.

Complete your Motorized Wheelchair Evaluation Form online today to ensure timely processing of the evaluation.