Homemaker Quarterly Eligibility Re-Assessment        Circle one:    Q2  Q3  Q4

Client Name: _____________________________Date____________Done by___________________   

Address / Phone/ Emergency Contact:  	No change   		Change
Change to:
________________________________________			___________________________________
________________________________________			___________________________________

Yes  No     Does the person drive or go out for more than doctor appointments or occasional accompanied outing?
Yes  No     Is the person able to prepare meals, shop for household/personal items, do light housework, etc.? 
Yes  No     Are there others in the household who are willing and physically capable of performing Homemaker duties?
	
□	The participant is no longer eligible for Homemaker services because:     ________________________________________________________________________________________________________________________________________________________________________________
			Date service discontinued ______________________________ 
			Follow-up:   Family     Another agency_________________________ 

□	If the answer to any of the above was Yes, the participant may not be eligible for Homemaker services  unless otherwise noted here:______________________________________________________________
         _______________________________________________________________________________
Comments: ________________________________________________________________________________________________________________________________________________________________________________________________

                                 Homemaker Quarterly Eligibility Re-Assessment        Circle one:    Q2  Q3  Q4

Client Name: _____________________________Date____________Done by___________________   

Address / Phone/ Emergency Contact:  	No change   		Change
Change to:
________________________________________			___________________________________
________________________________________			___________________________________

Yes  No     Does the person drive or go out for more than doctor appointments or occasional accompanied outing?
Yes  No     Is the person able to prepare meals, shop for household/personal items, do light housework, etc.?
Yes  No     Are there others in the household who are willing and physically capable of performing Homemaker duties?
	
□	The participant is no longer eligible for Homemaker services because:     ________________________________________________________________________________________________________________________________________________________________________________
			Date service discontinued ______________________________ 
			Follow-up:    Family      Another agency_________________________ 

□	If the answer to any of the above was Yes, the participant may not be eligible for Homemaker services unless otherwise noted here:_______________________________________________________________
         ______________________________________________________________________________________
Comments: ________________________________________________________________________________________________________________________________________________________________________________________________
														Rev 13-14