DEPARTMENT OF HEALTH SERVICES Division of Long Term Care F-22568 (07/2008)
STATE OF WISCONSIN ss. 46.90(8)(c)
ELDER ABUSE DIRECT SERVICE EXPENDITURES
Completion of reports to the department is authorized under ss. 46.90(8)(c). Failure to complete required reports may result in loss of funding to the county.
Name - County Allocation
Today's Date (mm/dd/yyyy) Name - Person Reporting
I. Persons Served Number of persons served during calendar year: Have elder abuse reports been submitted for each person? If "No," why not? Yes No
II. Is your Elder Abuse Interdisciplinary Team (I-Team) operational? Yes If so, how often did it meet? Monthly Quarterly Other (How frequently?) What do you regard as your I-Team's biggest accomplishments for this past year?
What has been the biggest obstacle in the operation of your I-Team?
III. Use of Funds In-Home Services (e.g. Supportive Home Care) Service Coordination (e.g. assessment, case management, crisis intervention) Respite / Adult Day Care Residential Care (e.g. Adult Family Home, CBRF) Advocacy and Legal Services Counseling / Therapeutic Resources Domestic Abuse Program Efforts Interdisciplinary Team Activity Training / Outreach (No more than 10% of allocation can be spent in this category.) Other: Other: Other: Other: Other: TOTAL:
$ $ $ $ $ $ $ $ $ $ $ $ $ $ $
Return by this form by March 1 of each year to: Monica Smith, BADR, PO Box 7851, Madison, WI 53707-7851 or via email at monica.smith[email protected] . You must also submit a copy of this completed form to your Area Agency on Aging.