Form 2276, Intake

Instructions for Opening a Form

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Effective Date
10/2021
2276.pdf (249.3 KB)
2276-S.pdf (251.15 KB)

Instructions

Updated: 10/2021

Purpose

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

Procedure

When to Prepare

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

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

Date — Enter the date of information collection.

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

Primary Language — Enter the person’s primary language.

Last Name — Enter the person’s last name.

First Name — Enter the person’s first name.

MI — Enter the person’s middle initial.

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

City — Enter the city where the person resides.

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

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

County — Enter the county where the person resides.

Area Code and Phone No. — Enter the person’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 person's date of birth.

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

Email Address — Enter the person’s email address.

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

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

City — Enter the city where the person receives mail.

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

County — Enter the county where the person receives mail.

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

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

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

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

Person Lives Alone? — Check the appropriate box to indicate if the person 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 person 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 person’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 person is or is not in poverty.

Monthly Income From — Enter the monthly income amounts for the person and their spouse.

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 person needs.

Are you enrolled in? — Check the appropriate box to indicate if the person is enrolled in Medicare, Medicaid, or both.

Part III

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

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

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

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

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

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

Part IV

Referral — To be completed by AAA or provider staff.

Referred By — Check the appropriate box to indicate how the person was referred to the Area Agency on Aging or provider.

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

Date — Enter the form completion date.

Part V

Nutrition Services — To be completed by AAA or provider staff.

Additional Eligibility Requirements — Check the appropriate box to indicate why a person under 60 is receiving a congregate or home delivered meal.