Appendix D Forms and Templates

User Form/Template Owner Form Number Form/Template Name Instructions

AAA

DAS/RC

AAA Program Monitoring Log

On page 1

AAA

DAS/LC

Alzheimer’s Disclosure Form

AAA

DAS/LC

HCBS Income Worksheet

HCBSIWi

AAA

DAS/PI

Older Americans Act Federal Allocation Match Analysis (EXCEL)

AAA

DAS/PI

Uniform Cost Methodology (EXCEL)

AAA

DAS/PI

Uniform Cost Methodology Spreadsheet Checklist Form

AAA

DAS/Bus Ops

Waiver Template

Waiver Instructions

AAA

DAS/Bus Ops

Checklist for Disposal of Electronic Records

DAS

DAS/PI

DAS Data System Change Request

DDSi

DAS

DAS/PI

DAS Data System Report Request

DDSRR instructions

DAS

DAS/PI

DAS Data System Report Approval Form

DAS

DAS/PI

DAS Data System Issue Log

DAS

DAS/PI

DAS Data System Worker Change Request Form

DAS

DAS/PI

Measurement and Analysis Plans (MAPS) form and instructions

Providers

DAS/Bus Ops

TERF Vendor Package

TERFi

DAS

DAS

713

Interagency/Inter Office Referral Follow-Up

DAS

DHS

5459

Authorization for Release of Information

5459i

DAS

DHS

Notice of Privacy Practices

DAS

DHS

Notice of Privacy Practices (Spanish)

DAS

DHS

5480

DHS Transmittal Approval Request

DAS

DAS/PI

RC-1

Project Form

DAS

DAS/PI

RC-2

AAA Programmatic Monitoring Log

DAS

DAS/Bus Ops

Commissioner’s Cover Letter for Grants

DAS

DAS/DO

Manual Section Template

MSTi

DAS

DAS/DO

Manual Transmittal Cover Letter Template

CLi

DAS

DAS/PI

Outcome Statement Template

DAS

DAS/Bus Ops

Supply Order Prior Approval

DAS

DAS/Legal

Response Letter to Records Request

RLRRi

DAS

DAS/PI

Team Charter Template

DAS

DAS/DO

Volunteer Application (Sample)

DAS

DAS/DO

Volunteer Interview Questions (Sample)

DAS

DAS/DO

Volunteer Job Description Template

DAS Onboarding

DAS

DAS/DO

Onboarding Checklist

DAS

DAS/DO

Work Schedule Request

DAS

DAS/Training

Access to Services OJT Checklist

DAS

DAS/Training

Adult Protective Services OJT Checklist

DAS

DAS/Training

Business Operations OJT Checklist

DAS

DAS/Training

Dementia Care Specialist OJT Checklist

DAS

DAS/Training

Director’s Office OJT Checklist

DAS

DAS/Training

Forensic Special Initiatives Unit OJT Checklist

DAS

DAS/Training

Georgia Council on Aging OJT Checklist

DAS

DAS/Training

Intern OJT Checklist

DAS

DAS/Training

Livable Communities OJT Checklist

DAS

DAS/Training

Long Term Care Ombudsman OJT Checklist

DAS

DAS/Training

Program Integrity OJT Checklist

DAS

DAS/Training

Public Guardianship Office OJT Checklist

DAS

DAS/Training

Program/Platform List

DAS

DAS/Training

Supervisor Checklist

DAS Offboarding

DAS

DAS/DO

Acceptance of Resignation Letter Template

AoRi

DAS

DAS/DO

Offboarding Checklist