Free Alzheimer's Family and Caregiver Support Program Annual Fiscal Report - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Long Term Care F-20906 (Rev. 08/2008)

STATE OF WISCONSIN Wisconsin Statutes 546.87

ALZHEIMER'S FAMILY AND CAREGIVER SUPPORT PROGRAM ANNUAL FISCAL REPORT
Instructions: Submit completed report to the Bureau of Aging and Disability Resources, P.O. Box 7851, Madison, WI 53707-7851 by March 15 of each year. Also submit copies to your Division of Enterprise Services (DES) Human Services Area Coordinator or your Area Agency on Aging. This is a required form. Failure to submit reports will result in withholding of allocation.

Name - County / Department Name - Person Completing Report

CY Total 20 I. SUMMARY OF PROGRAM INFORMATION A. Number of households enrolled and served. B. Number of persons in community-based residential Facilities (CBRFs) and adult family homes. Number of households or persons not enrolled but who benefited indirectly by AFCSP expenditures (e.g., support groups, information, brochures). Number of households on a waiting list at the end of the reporting period. Non client specific funds used to develop new or expand existing services.

C.

D. E. II.

AMOUNT OF AFCSP FUNDS EXPENDED BY SERVICE TYPE A. Adult day care (SPC 102) B. C. D. E. F. Respite care (SPC103) Supportive home care (SPC 104) Caregiver support group(s) (SPC 408) Case management (SPC 604) Other service expenditures which amounted to more than 10 percent of the county AFCSP allocation 1. 2. 3. All other services Administrative services (10% maximum) TOTAL AFCSP EXPENDITURES: THIS YEAR'S ALLOCATION: CARRYOVER FROM PRIOR YEAR USED THIS YEAR:

$ $ $ $ $

$ $ $ $ $ $ $ $

G. H.