DOH Mandated Forms for ACFs, ALRs and ALPs

DOH Forms

• Assisted Living Residence Medical Evaluation (DOH-3122, Rev 5/12) (PDF, 60KB, 3pg.)
• ACF Waiver Request/Equivalency Notification Form (DOH-4235) (PDF, 30KB, 3pg.)
• Assisted Living Residence Personal Data and Resident Evaluation (DOH-4397) (PDF, 112KB, 8pg.)
  • Assisted Living Residence Personal Data and Resident Evaluation Instructions (DOH-4397INSTR) (PDF, 53KB, 9pg.)

DSS Forms

• Incident Report (DSS-3123) (PDF, 21KB, 2pg.)
• Notice of Change Enriched Housing Apartment Certification (DSS-934) (PDF, 21KB, 1pg.)
• Statement Offering Personal Allowance Account (DSS-2853) (PDF, 21KB, 1pg.)
• Personal Allowance Ledger (DSS-2854) (PDF, 28KB, 1pg.)
• Personal Allowance Summary (DSS-2855) (PDF, 97KB, 2pg.)
• Daily Resident Census Report (DSS-2900) (PDF, 128KB, 1pg.)
• Personal Data Sheet (DSS-2949) (PDF, 43KB, 1pg.)
• Chronological Admission and Discharge Register (DSS-3026) (PDF, 37KB, 2pg.)
• Inventory of Resident's Property Held by Facility for Safe Keeping (DSS-3027) (PDF, 21KB, 1pg.)
• Statement of Purpose - Medical Evaluation (DSS-3122) (PDF, 35KB, 2pg.)
• Statement of Administrator Qualifications – for Adult Residential Care Facilities (DSS-3233) (PDF, 126KB, 2pg.)
• Identifying Data (DSS-4449B) (PDF, 17KB, 1pg.)
• Medical Evaluation (DSS-4449C) (PDF, 29KB, 2pg.)
• Assisted Living Program Nursing/Functional/Social Assessment (DSS-4449D) (PDF, 48KB, 2pg.)
• Assisted Living Program Interim Assessment (DSS-4569) (PDF, 13KB, 1pg.)