Appendix G Assessment and Investigation Forms

Georgia State Seal

Department of Human Services

Policy and Manual Management System

Index:

MAN 5500

Effective Date:

09/16/2021

Next Review Date:

09/16/2023

Subject: Division of Aging Services Adult Protective Services

User Form Owner Form Number Form Name Instructions Revision Date

APS/Invest

DAS

Authorization for the Release of Information – Form 5459 (English)

APS/Invest

DAS

Authorization for the Release of Information – Form 5459 (Spanish)

APS/Invest

DAS

DHS Notice of Privacy Practices (HIPAA) – Form 5460 (English)

APS/Invest

DAS

DHS Notice of Privacy Practices (HIPAA) – Form 5460 (Spanish)

APS/Invest

DAS

Determination of Need - Revised (DON-R)

DON-Ri

APS/Invest

DAS

Saint Louis University Mental Status (SLUMS) Examination

SLUMSi

APS/Invest

DAS

Patient Health Questionnaire – 9 (PHQ-9)

PHQ-9i

APS/Invest

DAS/APS

APS Income Worksheet

APS/Invest

DAS/Access to Services

ADRC Risk Assessment for Institutional Placement

APS/Invest

DAS/CCSP

Falls Risk Assessment

APS/Invest

DAS/HCBS

Food Security Survey Form

APS/Invest

DAS/APS

Guardianship or Conservatorship Referral Form

APS/Invest

DAS/APS

Guardianship Filing Checklist

GFCi

APS/Invest

DAS/APS

Diligent Effort to Locate

APS/Invest

DAS/APS

Assessment Matrix

APS/Invest

DAS/APS

Investigation Matrix

APS/Invest

DAS/APS

Disabled Adult Abuse Report

APS/Invest

DAS/APS

Medical Records Request

APS/Invest

DAS/APS

Out-of-State Request Reporting Form