Application for General Infirmary Service, Hospital Authority. Name (English): (Chinese): Date of birth (dd/mm/yyyy) :

Transcription

1 RESTRICTED LDS Form 5a (Infirmary) (6/2012) For Official use only LDS Serial No.: Application for General Infirmary Service, Hospital Authority Note: 1. Please complete this form in English and * tick as appropriate 2. Application form should be sent in duplicate to Central Infirmary Waiting List Office (Attn: CM(PCS), Hospital Authority, M/F, Health InfoWorld, Hospital Authority Building, 147B, Argyle Street, Kowloon. 3. Enquiry: (Mon Fri: 10:30am 12:00 noon / 2:30pm 4:30pm) 4. Fax No.: Part I Applicant s Personal Data Name (English): (Chinese): HKID: Date of birth (dd/mm/yyyy) : Cert. of Exemption No. (if no HKID): Dialect: Sex: Marital Status: Married /Single/ Widowed/ Divorced (please circle) Address where applicant is currently residing: Tel: Name of institution (for those whose current residence is an institution of any kind): District of residence of the above address * Hong Kong Kowloon The New Territories 1. Central & Western 6. Kwun Tong 14. Shatin 2. Islands 7. Wong Tai Sin 15. Tai Po 3. Eastern 8. Sai Kung 16. North 4. Wan Chai 9. Tseung Kwan O 17. Yuen Long 5. Southern 10. Kowloon City 18. Tsuen Wan 11. Sham Shui Po 12. Yau Tsim 13. Mong Kok 19. Kwai Tsing 20. Tuen Mun Particulars of family members or relatives Name (both Chinese and English) Relationship to Applicant Sex Age Occupation/ Schooling Tel No. 1

2 Type of Accommodation * (01) Self-care hostel for the elderly (02) Home for the Aged (03) C&A home (04) Nursing home (05) Self-financing aged home (06) Private aged home (07) Housing for senior citizens (09) Street sleepers shelter (10) Public housing other than housing for senior citizens (11) Private tenement (12) Infirmary (Hospital Authority) (13) Hospitals other than infirmary (14) Others (please specify) Community support services received (may have more than one entry) * Nil Residential care (Care & Attention) Residential care (Nursing Home) Day care centre for the Elderly / Day Care Unit (DCU) Enhanced Home & Community Care service / Integrated Home Care Service (Frail Case) Home Help/Integrated Home Care Service Team (Ordinary Case) Social Centre for the Elderly (S/E) / Neighbourhood Elderly Centre (NEC) District Elderly Community Centre (DECC) Home for the Aged / Self-care Hostel for the Elderly Others (please specify) Social network * (01) Living alone without family and relatives (02) Living with family or relatives (03) Applicant with family members but not living together Major financial source (select one item only) * (01) CSSA Standard rate (05) CSSA standard rate for 50% disabled/elderly (06) CSSA standard rate for 100% disabled (07) CSSA standard rate for person in need of constant attendance (02) Self-supporting (savings, pension, income form rent) (03) Family members/relatives (08) NOAA / HOAA (please circle) (09) NDA / HDA (please circle) (04) Others (please specify) If the Applicant is a recipient of DA, please indicate: Normal DA / Higher DA (please circle) 2 CSSA/SSA No.: (if applicable)

3 Part II Preliminary Assessment of Applicant's Care Needs (ALL parts in this section should be completed) Assessment of Health Condition: Mental state* Points Normal/alert 1 Disturbed /Confused 2 Apathetic 3 Stupor/impaired conscious state 5 Description: Mobility* Points Independent without aid 1 Self-ambulatory with walking aid or wheelchair 2 Require one person to assist in order to move 3 Bed-bound 5 Description: Continence state* Points Normal 1 Occasional urine or faecal soiling 2 Frequent urine or faecal soiling 3 Uncontrolled incontinence 5 Description: For eligibility to application for infirmary care, total score > 8 or mobility = 5 may be taken as reference. Activities of Daily Living (ADL) (I=Independent A=requires Assistance D=totally Dependent on others) Eating Transfer Dressing Mobility Toileting Bathing Instrumental Activities of Daily Living (IADL) (I=Independent A=requires Assistance D=totally Dependent on others) Use telephone Go out Purchase items Cook Housework Wash clothes Take Medication Handle finance Vision/Sight (with corrective devices)* Normal Unable to read newspaper print Unable to watch TV See lights only 3

4 Social Need Assessment Assessment On Ability of Current Care Provider In Providing Care to Applicant: Assessment On Degree of Risk for Applicant under the Current Support System: Remarks on Availability of Other Alternative, Including Informal Support & Community Support Services, in Assisting the Applicant To Be Cared In Community Continuously: Applicant s Consent for Admission Consent has been obtained directly from applicant on Consent has been obtained from relatives/friends on Consent has not been obtained because (please give reasons): Part III Case Summary (obtained from applicant or his/her family) 1. Other medical condition (medical diagnosis): 2. Medical clinics attending : 3. Clinic follow-up number(s) : 4. Drug and treatment receiving : 5. History of abnormal behaviour : 6. History of drug addiction and alcoholic dependency : 4

5 Part IV Regional Preference (For Normal Central Infirmary Placement only) Please tick the appropriate box (ONE entry only) The applicant has no regional preference Hong Kong region [including Cheshire Home (Chung Hom Kok) and St. John Hospital] Hong Kong region [excluding Cheshire Home (Chung Hom Kok)] Hong Kong region [excluding St. John Hospital] Hong Kong region [excluding Cheshire Home (Chung Hom Kok) and St. John Hospital] Kowloon region The New Territories For more information on distribution of Central Infirmaries by region, admission procedures of central infirmary placement, and other Frequently Asked Questions, you may refer to Hospital Authority General Infirmary Service in Hospital Authority s web site ( ). Disclaimer: This is an application form only. Applicants may not be allocated infirmary placement, if, after assessment, applicant can be cared at residential placement other than infirmary. Other information relevant to General Infirmary Service: 5

6 Part V Source of Referral Referring office: [SWD / NGOs / HA (please circle)] Address: File No. Tel No.: Fax No.: Remarks: Will the application for general infirmary service be transferred to other office for follow up? No Yes (All correspondence including acknowledgment letter will be sent to this office. Please specify details below) Name of Office: [SWD/NGOs/HA (please circle)] Address: Tel No.: I, the Responsible Officer, hereby confirm that the applicant has been notified that the information contained in this form may be used by the Social Welfare Department, the Hospital Authority and the relevant parties (such as government bureaux) for consideration of his/her application for admission into long term care services related purposes. Signature : Name of Responsible Officer : Tel No. : Date : Supervisor s Endorsement I have examined the case file as well as information provided in this application form, and am satisfied that the applicant is in need of the general infirmary service. Signature : Name of Supervisor : Tel No. : Date : 6