Service Provider Forms
Following are templates provided to our service providers to support regulatory compliance. This list is not all inclusive and requirements are subject to change. Any questions regarding compliance may be directed to communityservices@elarc.org.
- Vendor Claim Form(PDF, 30KB)
- Special Incident Report (SIR) Form
- 501 SIR Facility and Program(PDF, 45KB)
- 501a SIR PRN (Psychotropic)(PDF, 24KB)
- 502 Personal Possessions(PDF, 37KB)
- 503 Physical Exam(PDF, 77KB)
- 504 Record of Seizures(PDF, 27KB)
- 505 Immunizations and Tests(PDF, 37KB)
- 506 Placement Information(PDF, 100KB)
- 507 Admission Agreement Addendum (Temporary Constraint)(PDF, 80KB)
- 510 House Rules, Grievance Procedure(PDF, 27KB)
- 511 Semi-Annual Report(PDF, 23KB)
- 512 Client Notes(PDF, 22KB)
- 513 Weight Record(PDF, 28KB)
- 514 Physician Notes Client(PDF, 26KB)
- 515 Physician Notes Medication(PDF, 26KB)
- 516 Visit Information Medical & Specialist(PDF, 25KB)
- 517 Visit Information Dental(PDF, 28KB)
- 518 Medication Administration Record (MAR)(PDF, 29KB)
- 519 Document Request Letter SAMPLE Residential(PDF, 19KB)
- 520 Fire & Disaster Drills(PDF, 22KB)
- 521 Staff Schedule(PDF, 26KB)
- 522 DSP On Site Orientation(PDF, 31KB)
- 523 DSP On the Job Training(PDF, 28KB)
- 524 Continuing Education ADMINISTRATOR Residential(PDF, 27KB)
- 525 Continuing Education DSP(PDF, 33KB)
- 526 Cash Handling(PDF, 22KB)
- 527 Staff Review Checklist(PDF, 51KB)
- 528 Table of Contents(PDF, 22KB)
- 529 Review Record Checklist(PDF, 34KB)
- 530 Cash Resources Guidelines(PDF, 200KB)
- 531 Functional Behavioral Assessment & Intervention Guidelines(PDF, 86KB)
- 532 Behavioral Intervention Plan Report Checklist(PDF, 137KB)
- 533 Consultant Services Log(PDF, 103KB)
- 534 Additional Components (Level 4)(PDF, 25KB)
- 535 Health Care Guidelines for Adults(PDF, 109KB)