Free Living Unit Census Report-F-62155 - Wisconsin

DEPARTMENT OF HEALTH SERVICES
Division of Quality Assurance F-62155 (Rev. 07/08)

STATE OF WISCONSIN

LIVING UNIT CENSUS REPORT
Name ­ Facility Name ­ Living Unit License Number Review Dates From

To

INSTRUCTIONS
Complete one form for each living unit following the steps below and attach to the color coded forms. Refer to DQA form F-62155I for more information. 1. 2. 3. Determine the DD level of care for each client of the living unit. Write the total in the appropriate daily space on the lines labeled DD Daily Census. Determine the number of clients who attended school, vocation, or workshop programs that were off the living unit. Record this number in the appropriate space. Determine the number of hours per shift that persons in each level spent off the living unit in school, vocations, or workshop programs. For example, a program running from 1:00 PM to 5:00 PM would have 2.5 hours credited to a day shift that runs from 7:00 AM to 3:30 PM, and 1.5 hours credited to the evening shift. Total the hours per shift and write this number in the appropriate space. Express fractions as decimals rounded to the nearest quarter, i.e., .25, .5 or .75.
Sun Mon Tues Wed Thur Fri Sat Sun Mon Tues Wed Thur Fri Sat

1. 2. 3.

DD-1a Daily Census Number Attending Off Unit Programs Hours Off Unit On DAY Shift Hours Off Unit On EVENING Shift

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DD-1b Daily Census Number Attending Off Unit Programs Hours Off Unit On DAY Shift Hours Off Unit On EVENING Shift

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DD-2 Daily Census Number Attending Off Unit Programs Hours Off Unit On DAY Shift Hours Off Unit On EVENING Shift

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DD-3 Daily Census Number Attending Off Unit Programs Hours Off Unit On DAY Shift Hours Off Unit On EVENING Shift