DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance F-62155I (Rev. 07/08)
STATE OF WISCONSIN CFR 483.430 (c) and (d) DHS 134.60(2), Wis. Admin. Code
LIVING UNIT CENSUS AND DIRECT CARE STAFF REPORTS INSTRUCTIONS
These instructions apply to the following forms:
F-62155 Living Unit Census Report F-62156 Living Unit Direct Care Staff Report Day Shift F-62157 Living Unit Direct Care Staff Report Evening Shift F-62158 Living Unit Direct Care Staff Report Night Shift
Collection of this information is required under the provisions of CFR 483.430(c) and (d) and DHS 134.60(2), Wis. Admin. Code. Failure to provide this information may affect the facility's licensure or certification.
Name Facility City License Number
Complete the enclosed forms by providing the requested information for the 2 week period.
Questions about completion of the enclosed forms may be directed to the staff person listed below.
Name Staff Telephone Number
A Living Unit Census Report, F-62155 and the Living Unit Direct Care Staff Reports, F-62156, F-62157, and F-62158, must be completed for each client living unit in your facility. The following factors are to be considered when identifying the number of "client living units":
A "living" unit, as defined in Chapter DHS 134, Wis. Admin. Code, is the area of the facility where client bedrooms are located and may include dining and activity space. The physical plant layout can be the major determinant when identifying client living units, i.e., living units can be separate floors of a multi-story building or distinct units or wings that are located on the same floor. A living unit can be identified by the facility staffing patterns or assignments.
Return all materials to the address below, no later than: