Section 5 - Service Coordinator Observations The following questions are based upon the Service Coordinator’s observations and are to be answered by the Service Coordinator only. Are any of the following concerns present? all that apply) Bruising Lack of family cooperation Poor physical appearance Possible fraud/financial mismanagement Wounds/pressure sores Non-compliance with service plan Signs of abuse Depression Malnourishment None of neglect Other Dementia/confusion Please describe each concern (including severity): Are there any environmental conditions that jeopardize the health and welfare of the participant? (Check all that apply) Lack of food Unsafe food handling Cleanliness Pet problems Lack of electricity Home not accessible to participant/provider No phone Insect/rodent infestation No heat/air Pending eviction or foreclosure Trash accumulation posing fire hazard None No running Other Utility Shutoff Please describe (including severity):
Section 5 - Service Coordinator Observations The following questions are based upon the Service Coordinator’s observations and are to be answered by the Service Coordinator only. Are any of the following concerns present? all that apply) Bruising Poor physical appearance Wounds/pressure sores Signs of abuse Malnourishment of neglect Dementia/confusion Lack of family cooperation Possible fraud/financial mismanagement Non-compliance with service plan Depression None Other Please describe each concern (including severity): Are there any environmental conditions that jeopardize the health and welfare of the participant? (Check all that apply) Lack of food Cleanliness Lack of electricity No phone No heat/air Trash accumulation posing fire hazard No running Utility Shutoff Unsafe food handling Pet problems Home not accessible to participant/provider Insect/rodent infestation Pending eviction or foreclosure None Other Please describe (including severity):