Frederick County Department of Aging Meals on Wheels and Home Delivered Meal Service Application Name Address Apt. # Apartment Complex or neighborhood City/State/Zip Primary Phone Date of Birth Secondary Phone Email Name/Relationship of Others Living In Home Referred by Relationship Phone ******************************************************************************************* We request the following personal information for statistical purposes only. Providing it is optional and has no impact on your eligibility or participation in the Meals on Wheels / Home Delivered Meals program. Caucasian African American Native American/Alaskan Asian/Pacific Islander Other 2 or more Declined to answer Did you or your spouse serve in the military? Male Female Other Declined Single Married Widowed Divorced Separated Unknown Declined Yes No Declined to answer How many pets are in the house? Dog(s) Cat(s) Other Do you need assistance with pet food? Yes / No Are You a Registered Voter? Yes No would you like a form? Yes / No Declined to answer Are there firearms or other weapons in the home? Yes No Decline to Answer Please be advised that all weapons are required to be unloaded and stored in a safe and secure manner when volunteers and staff make meal deliveries and home visits. Failure to do so could result in immediate suspension or termination of service. FOR OFFICE USE ONLY [date (mm/dd/yyyy) and initial as completed] Referral Received Initial Screen Completed Priority Level (from page 2) A / B / C / D / E Hispanic Non Hispanic Declined AIM Case Number Withdrawn/ Denied Reason for Home Visit Completed AIM Entry Completed Nurse Review MoW Log Entry Completed Route Assignment Map Quest Completed Service Initiated Service Discontinued
Initial Eligibility Screen Please check all that apply. 1a) If you had groceries available, would you be able to use them to prepare meals? Yes [Skip to Question 2] No [Ask Question 1b] 1b) Do you have reliable help with meal preparation? Yes [Continue to Question 2] No Stop Questionnaire: APPLICANT IS LEVEL A PRIORITY 2.During the last month... a).how often was this statement true: The food that we bought just didn't last, and we didn't have money to get more. Often (1 point) Sometimes (1 point) Never (0 points) b)...how often was this statement true: We couldn't afford to eat balanced meals. Often (1 point) Sometimes (1 point) Never (0 points) c)...did you or other adults in your household ever cut the size of your meals because there wasn't enough money for food? Yes, on 3 or more days (1 point) Yes, on 1 or 2 days (1 point) d)...did you or other adults in your household ever skip meals because there wasn't enough money for food? Yes, on 3 or more days (1 point) Yes, on 1 or 2 days (1 point) e)...did you ever eat less than you felt you should because there wasn't enough money for food? Yes (1 point) f)...were you ever hungry but didn't eat because you couldn't afford enough food? Yes (1 point) Add up the points from Questions 2a-f and enter in this blank: 3) Are you able to get groceries into your home when you need them? Yes " Select the range this applicant s score from 2a-f fits into: Score is 0-1 " Stop Questionnaire: APPLICANT IS LEVEL E PRIORITY Score is 2-6 " Stop Questionnaire: APPLICANT IS LEVEL C PRIORITY -2- No " Select the range this applicant s score from 2a-f fits into: Score is 0-1 " Stop Questionnaire: APPLICANT IS LEVEL D PRIORITY Score is 2-6 " Stop Questionnaire: APPLICANT IS LEVEL B PRIORITY This applicant s Food Security Priority Level
Nutrition Screening Yes No Eats less than 5 servings of Fruits/Vegetables/Dairy products per day? Yes No Eats less than 2 meals per day? Yes No Has 3 or more alcoholic drinks per day? Yes No Has a dietary influenced illness? Yes No Has tooth/mouth problems that affect ability to eat? Yes No Has unintentional weight fluctuations of 10 or more pounds in the last 6 months? Yes No Lacks money to purchase food on a regular basis? Yes No Is unable to shop for or cook food on a regular basis? Yes No Uses 3 or more prescription and/or over the counter medications per day? Yes No Usually eats alone? -3- Number of Yes answers. Diet Requirements: Regular Diet (A Heart Healthy diet designed to be low in sodium, sugar and fat. This diet is suitable for most people, including diabetics who control their condition with diet and medication. Diabetic Diet/ Low Carbohydrate Diet* Mechanical Soft Diet* Low Fat Diet* Low Cholesterol Diet* Low Sodium Diet* Rx mg Na Other* *A prescription is required from your health care provider. Please note, not all vendors preparing meals are able to provide prescription diets. Does the applicant have any food allergies? Please specify While every attempt will be made to exclude allergy causing foods, the Frederick County Department of Aging and the vendor are not able to guarantee such food items do not come in contact with, or are included in meals provided to Meals on Wheels clients. It is the individual meal recipient s responsibility to examine the food provided, and avoid items that may cause an allergic reaction. Please note that Maryland Department of Aging regulations require specific food components be included in the meals provided to Meals On Wheels recipients. This program does not offer individual menu choice or accommodate specific food requests and substitutions.
-4- Health Conditions: Check all that apply Arthritis Cancer Depression Dementia Diabetes Developmental/Intellectual Disability Hearing Loss Heart Disease High Blood Pressure Mental Illness Neuromuscular Disease Medications- Respiratory Disease Traumatic Brain Injury Seizures Stroke Parkinson s Disease Post Surgical Vision Loss History of Alcohol or Drug Abuse Other Other Other Please list prescription, over-the-counter medications, and herbal supplements currently being used. Medication Dosage Condition being treated Notes Primary Health Care Provider Name Specialty Address City/State/Zip Phone
-5- Emergency Contact #1 Name Relationship Address City/State/Zip Primary Phone Secondary Phone Email Emergency Contact #2 Name Relationship Address City/State/Zip Primary Phone Secondary Phone Email Person Responsible for Financial Contributions if not the applicant. Name Relationship Address City/State/Zip Primary Phone Secondary Phone Email Agencies Currently Providing Assistance: Agency Contact Person, Title Phone Reason for service Agency Contact Person, Title Phone Reason for service Agency Contact Person, Title Phone Reason for service
Financial Benefits Screening: If Single, is the applicant s monthly income under or over $981* Declines to answer If a Couple, is their combined monthly income under or over $1328* Declines to answer *2015 Federal Poverty Guideline- Benefit Medicare/Medicaid/other health care insurance Medicare D (prescription drug coverage) QMB/SLMB LIS/SPDAP (Medicare A, B & D premium assistance programs) MEAP/EUSP (Energy Assistance programs) SNAP (Supplemental Nutrition Assistance Program formerly known as food stamps) Senior Care (In Home Assistance Program administered by the Dept. of Social Services) Frederick County Homeowners Tax Credit MD Homeowners Property Tax Credit Renters Tax Credit Are you currently enrolled? If not, would you like additional information? Date enrolled or application submitted and other comments: -6- Weatherization / Home Repair Assistance You may be eligible for additional benefits, services, and assistance. A representative will contact you directly to discuss eligibility guidelines and application procedures. The information provided on this application is true and accurate to the best of my knowledge. I agree to allow Frederick County Department of Aging staff to complete a home visit and evaluation prior to being approved for Meals on Wheels / Home Delivered Meals services. I agree to allow Frederick County Department of Aging staff to share pertinent information with other staff, partner agencies, and with representatives of agencies currently providing me with services, as appropriate. I agree to notify the Frederick County Department of Aging if information on my application changes (i.e. emergency contact information) I have read and understand the Meals on Wheels / Home Delivered Meal criteria for service and the contribution policy and would like to be contacted by a Frederick County Department of Aging staff person to continue the application process. Print Name Sign Date Return to the Frederick County Department of Aging by email to DeptofAging@FrederickCountyMD.gov, fax to 301.600.3554 or mail to Frederick County DoA/ Meals on Wheels, 1440 Taney Avenue, Frederick, MD 21702.