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Adult Family Home Resident Personal Belongings … - clothing inventory sheets printable free
AGING AND LONG-TERM SUPPORT ADMINISTRATION (ALTSA)
Adult Family Home Resident Personal Belongings Inventory
WAC 388-76-10320
Instructions: Provider or Resident Manager completes upon admission. The Provider/Resident Manager and the resident or the
resident's guardian or agent sign. File in the resident's record. Records and information concerning each person in
care shall be maintained in such a manner as to preserve confidentiality.
RESIDENT'S NAME NAME OF RESIDENT'S GUARDIAN DATE OF ADMISSION
CONTACT LENSES DENTURES
EYE GLASSES HEARING AID
JEWELRY WATCH
MONEY/CHECKBOOK/CREDIT CARDS OTHER
CLOTHING LIST
NUMBER ITEM DESCRIPTION
Bathrobe
Belt
Blouse
Brassiere
Coat
Dress
Girdle
Gloves
Handkerchief
Hat
House coat
Necktie
Nightgown
Pajamas
Pants
Shirts
Shoes
Skirts
Slippers
Slips
Socks
Stockings
Suit
Suspenders
Sweater
Undershirt
Underpants
Underwear - long
Vests
Other:
MISCELLANEOUS
NUMBER ITEM DESCRIPTION
Brush
Cane or crutches
Clock
Luggage
Radio
Television (model and serial number)
Walker
Wheelchair (model and serial number)
Other:
Statement: I have read and agree that this is an accurate list of my belongings.
PROVIDER'S/RESIDENT MANAGER'S SIGNATURE DATE RESIDENT'S OR GUARDIAN'S SIGNATURE DATE
DSHS 02-516 (REV. 07/2017)
Pdf INFO
Title: Adult Family Home Resident Personal Belongings Inventory
Subject:
Keywords:
Author: Millie Brombacher
Creator: Acrobat PDFMaker 11 for Word
Producer: Adobe PDF Library 11.0
CreationDate: Wed Jul 26 16:17:15 2017
ModDate: Wed Jul 26 16:17:16 2017
Tagged: yes
Form: none
Pages: 1
Encrypted: no
Page size: 612 x 792 pts (letter) (rotated 0 degrees)
File size: 35421 bytes
Optimized: yes
PDF version: 1.5
