Form 2270, Caregiver Intake

Instructions for Opening a Form

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Effective Date
10/2021
2270.pdf (281.22 KB)
2270-S.pdf (283.7 KB)

Instructions

Updated: 10/2021

Purpose

To collect initial intake information for applicants for Older Americans Act caregiver services.

Procedure

When to Prepare

Complete a Caregiver Intake form to collect demographic information, contact information, and other information needed for the coordination of appropriate services for each person requesting caregiver services.

Items marked with an asterisk are required for federal reporting and must be completed.

Number of Copies

Complete an original and keep original on file.

Transmittal

Area Agencies on Aging must follow their policy and procedures for Caregiver Intake. Enter the Caregiver Intake data in the State Unit on Aging Program Uniform Reporting System (SPURS).

Detailed Instructions

Area Agency on Aging of — Enter the name of the Area Agency on Aging.

Release of Information and Client Rights and Responsibilities — Check the box after explaining the Release of Information and Client Rights and Responsibilities to the person.

Part I

Caregiver Identification — To be completed by AAA or provider staff.

Date — Enter the date of information collection.

SPURS ID No. — Enter the caregiver’s identification number generated by SPURS, if known.

Primary Language — Enter the caregiver’s primary language.

Last Name — Enter the caregiver’s last name.

First Name — Enter the caregiver’s first name.

MI — Enter the caregiver’s middle initial.

Street Address and Apt No. — Enter the street address and, if necessary, apartment number where the caregiver resides.

City — Enter the city where the caregiver resides.

State — Enter the abbreviation of the state where the caregiver resides (i.e. enter TX for Texas).

ZIP Code — Enter the ZIP code where the caregiver resides.

County — Enter the county where the caregiver resides.

Area Code and Phone No. — Enter the caregiver’s area code and phone number and check the appropriate box to indicate if the number is for a home phone, cell phone, or other type of communication.

Date of Birth — Enter the caregiver's date of birth.

Gender — Check the appropriate box to indicate the caregiver’s gender. Check ‘Unknown’ if the person refuses to answer.

Email Address — Enter the caregiver’s email address.

Mailing Address — Check the appropriate box to indicate if the caregiver has an address for mailing that is different from the residential address.

Street Address and Apt No. or P.O. Box — Enter the caregiver’s mailing address and, if necessary, apartment number or P.O. Box.

City — Enter the city where the caregiver receives mail.

State — Enter the abbreviation of the state where the caregiver receives mail (i.e. enter TX for Texas).

ZIP Code — Enter the caregiver’s mailing ZIP code.

County — Enter the county where the caregiver receives mail.

Ethnicity — Check the appropriate box to indicate the caregiver’s ethnicity. Check ’Unknown’ if the person refuses to answer.

Race — Check the appropriate box to indicate the caregiver’s race.

Marital Status — Check the appropriate box to indicate the caregiver’s marital status. Check ‘Not Reported’ if the person refuses to answer.

Person Lives Alone? — Check the appropriate box to indicate if the caregiver lives alone or lives with other people.

Total Number of People in Household: — Enter the total number of people living in the same household as the caregiver requesting services.

Monthly Household Income: — Enter the total household income from all sources.

At or Below Poverty? — Check the appropriate box to indicate if the caregiver’s income is at, below or above the federal poverty level. Use the current Department of Health and Human Services Federal Poverty Guidelines for the size of the household to determine if the caregiver is or is not in poverty.

Part II

Service(s) Requested — To be completed by AAA or provider staff.

List of Requested Services: — Enter notes about the type of help the caregiver needs.

Part III

Emergency Contact Information — To be completed by AAA or provider staff.

Contact Name — Enter the first and last name of the caregiver’s emergency contact.

Relationship — Enter the emergency contact person’s relationship to the caregiver.

Area Code and Phone No. — Enter the area code and phone number of the caregiver’s emergency contact.

Primary Care Physician — Enter the first and last name of the caregiver’s primary care physician.

Area Code and Phone No. — Enter the area code and phone number of the caregiver’s primary care physician.

Part IV

Relationship to Care Recipient(s) — To be completed by AAA or provider staff.

Check the appropriate box to indicate the caregiver’s relationship to the care recipient:

  1. Relationship to care recipient(s) who is 60 or older or any age if diagnosed with Alzheimer’s disease or a brain disorder —Indicate the relationship of the caregiver to the older person who gets help from the caregiver. Caregiver must be 18 or older.
  2. Relationship to care recipient(s) who is 18 or younger — Indicate the relationship of the older relative caregiver to the person age 18 or younger who gets help from the caregiver. Does the caregiver live with the care recipient? — Check either yes or no.
  3. Relationship to care recipient(s) with disability who is 18 or more but not older than 59 — Indicate the relationship of the older relative caregiver to the person who gets help from the caregiver. Does the caregiver live with the care recipient? — Check either yes or no.

Part V

Care Recipient Identification — To be completed by AAA or provider staff.

Does the care recipient need an interpreter? — Indicate if the person receiving care from the caregiver needs an interpreter.

If yes, who helps in the interpretation? — Enter the first and last name of the person interpreting for the care recipient.

If the care recipient is 60 or older, complete the following:

Date — Enter the date of information collection.

SPURS ID No. — Enter the care recipient’s identification number generated by SPURS, if known.

Primary Language — Enter the care recipient’s primary language.

Last Name — Enter the care recipient’s last name.

First Name — Enter the care recipient’s first name.

MI — Enter the care recipient’s middle initial.

Street Address and Apt No. — Enter the street address and, if necessary, the apartment number where the care recipient resides.

City — Enter the city where the care recipient resides.

State — Enter the abbreviation of the state where the care recipient resides (i.e. enter TX for Texas).

ZIP Code — Enter the ZIP code where the care recipient resides.

County — Enter the county where the care recipient resides.

Area Code and Phone No. — Enter the area code and phone number of the care recipient and indicate if the number is for a home phone, cell phone, or other type of communication.

Date of Birth — Enter the care recipient's date of birth.

Gender — Check the appropriate box to indicate the gender of the care recipient. Check ‘Unknown’ if the person refuses to answer.

Email Address — Enter the email address of the care recipient.

Ethnicity — Check the appropriate box to indicate the ethnicity of the care recipient. Check ‘Unknown’ if the person refuses to answer.

Race — Check the appropriate box to indicate the race of the care recipient.

Marital Status — Check the appropriate box to indicate the marital status of the care recipient. Check ‘Not Reported’ if the person refuses to answer.

If care recipient is 18 or younger, or has a disability and is 18 or more but not older than 59, complete the following:

Name — Enter the first and last name of each person who receives help from the caregiver.

Date of Birth — Enter the date of birth of each person who receives help from the caregiver.

Gender — Enter the gender of each person who receives help from the caregiver.

Relationship to Caregiver — Enter the relationship to caregiver of each person who receives help from the caregiver.

Name of AAA or Provider Staff Completing Caregiver Intake — Enter the first and last name of the AAA or provider staff who completed the Caregiver Intake.

Date — Enter the form completion date.