Oregon Foster Homes – Adult Foster Home Placement Portal

1Resident information APD 0902

Basic identifying and admission details.

Full name

Preferred name

Date of birth

Preferred pronouns / gender identity

Height

Weight

Date of initial screening

Date of admission

Readmission?

Yes No

Date of readmission screening

Resident’s current address

Phone number

Prior living arrangement

Current living situation (detail)

How long?

Current primary caregiver

Caregiver phone number

2Insurance & payment APD 0902

Medicare #

Medicaid #

VA #

Medicaid status

Insurance carrier

Claim number

Case manager

Case manager phone

Person responsible for payment

Payment contact phone

3Resident representatives APD 0902

Responsible person

Name

Relationship

Address

Phone number

Other significant person

Name

Relationship

Address

Phone number

Emergency contact

Name

Phone number

4Additional contacts

Any other relatives, legal representatives, or providers worth tracking beyond the fields above.

5Medical professional information APD 0902

Primary physician

Name

Phone number

Address

Specialist

Name

Phone number

Address

Dentist

Name

Phone number

Address

Home health

Name

Phone number

Address

Pharmacy information

Preferred pharmacy

Phone number

Address

How will medications be delivered to the home?

Who is responsible for paying for the medications?

6Diagnoses & history

Select all current diagnoses or active impairments that apply.

Medical diagnosis (including illness and injury) — APD 0902

Behavioral support needs (including distressing, disruptive or potentially harmful symptoms) — APD 0902

7Medications

Current prescriptions, plus any practitioner-reviewed over-the-counter preferences.

Over-the-counter medications & supplements (reviewed by practitioner) — APD 0902

Treatments and therapies — APD 0902

8Professional orders

Signed practitioner orders for active treatments, therapies, or special diets.

Signed order(s) on file?

Yes No Verbal, pending signature

Notes on orders

9Advance directives APD 0902

Advanced health care directive

No Yes, copies attached

POLST (Physician Orders for Life Sustaining Treatment)

No Yes, copies attached

POA and/or Guardianship

No Yes, copies attached

Mortuary / funeral plan

10Registered nursing tasks APD 0902

Consultations needed

Tasks requiring teaching or delegation

Name of RN performing consultation/teaching/delegation

Phone number

11Medical equipment & supplies APD 0902

Mark whether the resident currently has (H) or needs (N) each item.

Incontinence supplies – type

Pressure relief device – type

Equipment supplier

Medical equipment supplier

Phone number

Address

How will supplies be delivered to the home?

Who is responsible for paying for the supplies?

12Interviews conducted APD 0902

The screening process must include interviews with multiple persons.

13Mental status APD 0902

Describe

14Activities of Daily Living (ADLs) — assistance level

Level of assistance required for each activity (your home’s own detailed scale).

15Bathing APD 0902

Describe

16Dressing APD 0902

Describe

17Toileting APD 0902

Describe

18Mobility, ambulation & transferring APD 0902

Describe

19Personal grooming & hygiene APD 0902

Describe

20Eating & dietary needs APD 0902

Dietary requirements (your home’s checklist)

Allergies

Describe

21Communication APD 0902

Describe

22Night needs APD 0902

Describe

23Activities, interests & preferences APD 0902

Other substance use

Describe

Meaningful lifestyle / activity preferences

24Emergency exiting APD 0902

Can this individual, along with all other occupants, evacuate the home in three minutes or less?

Yes, independently Yes, with assistance No

Describe

25Wandering & elopement APD 0902

Other

Describe

26Other care needs APD 0902

Check I (Independent), A (Assistance), or F (Full Assistance) for each.

27Risk management

Can this facility legally accommodate this resident under its current license classification?

Yes No Needs verification

Behavioral trends / other safety indicators

Classification reference (APD 0902):

Class 1 – may only admit residents who need assistance in no more than four ADLs
Class 2 – may admit residents who require assistance in all ADLs, but full assistance in no more than three
Class 3 – may admit a resident who requires full assistance in four or more ADLs, but only one resident who requires bed-care or full assistance with all ADLs

28Required disclosures

For CBC / Assisted Living settings.

For Adult Foster Home settings.

For I/DD foster home settings.

For Residential Care Facility settings.

Private-pay resident notified of right to a long-term care assessment?

Yes No N/A – not private pay

Form used

Date provided

Oregon private-pay residents must be formally notified of their right to a state long-term care assessment, documented on form SDS 913 or APD 0902.

29Summary of activities of daily living APD 0902

I = Independent · A = Assistance · F = Full Assistance

30Determination APD 0902

If you answer “No” to even one of the following, you may not admit the resident to your home.

31Signature APD 0902

Signature of licensee

Date

AFH / facility name

✓Overall recommendation

Your home’s own assessment of whether this is a good fit.

Good fit Fit with conditions Not a fit

Assessor name

Date of assessment

Assessor notes

📄Review & generate PDF

A summary of everything entered. Check it over, then generate the PDF.

Northern

Southern

Central

Eastern

OFH Assessment Tool

1Resident information APD 0902

2Insurance & payment APD 0902

3Resident representatives APD 0902

Responsible person

Other significant person

Emergency contact

4Additional contacts

5Medical professional information APD 0902

Primary physician

Specialist

Dentist

Home health

Pharmacy information

6Diagnoses & history

7Medications

8Professional orders

9Advance directives APD 0902

10Registered nursing tasks APD 0902

11Medical equipment & supplies APD 0902

Equipment supplier

12Interviews conducted APD 0902

13Mental status APD 0902

14Activities of Daily Living (ADLs) — assistance level

15Bathing APD 0902

16Dressing APD 0902

17Toileting APD 0902

18Mobility, ambulation & transferring APD 0902

19Personal grooming & hygiene APD 0902

20Eating & dietary needs APD 0902

21Communication APD 0902

22Night needs APD 0902

23Activities, interests & preferences APD 0902

24Emergency exiting APD 0902

25Wandering & elopement APD 0902

26Other care needs APD 0902

27Risk management

28Required disclosures

29Summary of activities of daily living APD 0902

30Determination APD 0902

31Signature APD 0902

✓Overall recommendation

📄Review & generate PDF

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