Utah Department of Administrative Services

Division of Archives & Records Service

County Schedule 19 Aging and Adult Services Records

 

ALTERNATIVES PROGRAM CASE FILES (Item 19-1)

These case files document the participation of individuals in the Alternatives Program (TAP). This is a state funded program designed to keep "high risk" individuals (18 years of age or older) as independent as possible in the least restrictive environment and to prevent premature institutionalization. A physician's statement must be obtained stating that services brought into the home are needed for individual to remain at home. Services include case management, homemaker services, respite care, nurses aide, equipment, and coordination with other agencies. Quarterly visits are made to evaluate the care. The files include yearly assessment forms, care plan, client's rights form, client contract, eligibility declaration, summary sheets, needs assessment forms (social and physical, a nurse does the physical assessment), and quarterly review visit forms.

RETENTION

Retain for 4 years after client leaves program and then destroy, provided all audits have been completed.

SUGGESTED PRIMARY DESIGNATION

Private.

(Approved 12/92)

CONGREGATE RESERVATION LIST (Item 19-2)

This list records reservations made for meals served at senior centers. It is used for meal planning and to create reports. The form includes center's name, dates, participant's names, days of week, indication of dates reservations made, whether meal served, and whether individual is a volunteer.

RETENTION

Retain for 1 year after final payment on contract and then destroy.

SUGGESTED PRIMARY DESIGNATION

Exempt:45 CFR 1321.51 (2008).

(Approved 12/92)

FOOD DELIVERY REPORT (Item 19-3)

This is a report on the condition of foods delivered to senior centers. It is used for compiling reports and for future planning. The report includes center name, date, time food arrived at center, temperatures for milk and hot and cold foods, homebound and congregate meals, time homebound meals left kitchen, a list of any missing items, a list of any additional foods, any comments from center staff and clients, and suggestions.

RETENTION

Retain until monthly report compiled and then destroy.

SUGGESTED PRIMARY DESIGNATION

Public.

(Approved 12/92)

FOOD INVOICES (Item 19-4)

This invoice lists foods being delivered to senior centers for congregate and homebound meals. It is used for planning purposes. The invoice includes date, center name, food list, alternatives provided, and signature.

RETENTION

Retain for 3 years after final payment on contract and then destroy.

SUGGESTED PRIMARY DESIGNATION

Public.

(Approved 12/92)

HOMEBOUND CARDS (Item 19-5)

These are cards on all clients receiving meals at home (Meals-on-Wheels). They are used for reference purposes. The cards include client's name, address and telephone number, days scheduled to receive meals, name and telephone number to contact in an emergency, physician's name and telephone number, date service started and date service cancelled.

RETENTION

Retain until superseded or 1 year after participation ends and then destroy.

SUGGESTED PRIMARY DESIGNATION

Exempt:45 CFR 1321.51 (2008).

(Approved 12/92)

HOMEBOUND MEALS CASE FILES (Item 19-6)

These case files document participation in the Homebound Meals Program (or Meals-on-Wheels). This is a program which provides one meal a day, five days a week, to a homebound person over the age of sixty. The meals are delivered by staff or volunteers and clients make donations pursuant to a suggested donation. The files include client application, eligibility form, intake evaluation form, disclosure form, and any related correspondence.

RETENTION

Retain for 4 years after client leaves program and then destroy, provided all audits have been completed.

SUGGESTED PRIMARY DESIGNATION

Exempt:45 CFR 1321.51 (2008).

(Approved 12/92)

HOMEBOUND MEALS EMERGENCY CARDS (Item 19-7)

These are cards used by the homebound program in emergency situations. They include client's name, address, and telephone number, meal schedule, any special instructions, physician's information, client's signature, and date.

RETENTION

Retain for 1 year after participation ends and then destroy.

SUGGESTED PRIMARY DESIGNATION

Exempt:45 CFR 1321.51 (2008).

(Approved 12/92)

HOMEBOUND RESERVATION LIST (Item 19-8)

This weekly list documents those individuals who have made reservations to receive meals at home under the Homebound Program (Meals-on-Wheels). It is used for meal planning and to create billings. The list include site, week and year, clients' names and addresses, days of week, indication which days reservations were made for delivery of meals, and a check by driver to indicate whether meal was delivered.

RETENTION

Retain for 1 year after final payment on contract and then destroy.

SUGGESTED PRIMARY DESIGNATION

Exempt:45 CFR 1321.51 (2008).

(Approved 12/92)

HOMEMAKER PROGRAM CASE FILES (Item 19-9)

These case files document the participation of persons in the Homemaker Program. This program provides homemaker assistance to low income disabled persons or persons over the age of sixty. The client is billed according to ability to pay. The files include an eligibility declaration, long term support form, client rights form, personal care/in-home rehabilitation form, actual number of hours spent per client, and any related correspondence.

RETENTION

Retain for 4 years after client leaves program and then destroy, provided all audits have been completed.

SUGGESTED PRIMARY DESIGNATION

Private.

(Approved 12/92)

HOMEMAKER TIME SHEET (Item 19-10)

This worksheet is used to record the amount and types of services that a homemaker has provided to a specific client. All information is transferred to an official payroll record. This information is used in the creation of reports. It includes date, client's name, homemaker's name, dates worked, hours worked and services provided per day (special diet supervision, feeding, dressing and grooming, child care, cooking and meal preparation, general housework, errands, etc.).

RETENTION

Retain for 3 years after contract ends and then destroy, provided all audits completed.

SUGGESTED PRIMARY DESIGNATION

Private.

(Approved 12/92)

MASTER PARTICIPANT LIST (Item 19-11)

These are lists of persons participating in specific senior center activities. They are used for planning purposes. They are updated at least annually. The lists include date, program or activity title, and participants' names.

RETENTION

Retain until superseded and then destroy.

SUGGESTED PRIMARY DESIGNATION

Exempt:45 CFR 1321.51 (2008).

(Approved 12/92)

PARTICIPANT CARDS (Item 19-12)

These are cards on all participants in senior center programs. These programs include both those held at the center and any others provided (e.g., friendly visits, homebound meals, reassurance calls). The cards record the individual's participation for four quarters. They are used to compile an annual report. They include participant's name, quarter and year, and code for services provided.

RETENTION

Retain for 1 year after participation ends and then destroy.

SUGGESTED PRIMARY DESIGNATION

Exempt:45 CFR 1321.51 (2008).

(Approved 12/92)

QUARTERLY PROGRAM PERFORMANCE REPORT (Item 19-13)

This is a quarterly statistical report on all programs administered by the agency which is submitted to the State Division of Aging. The state compiles statistics and returns the report to local agency for subsequent quarters and a final annual report.

RETENTION

Retain for 2 years after final payment on contract and then destroy.

SUGGESTED PRIMARY DESIGNATION

Public.

(Approved 12/92)

SENIOR CENTER ANNUAL REPORT (Item 19-14)

This report is submitted to the local aging and adult services administrative office on senior center activities. It compares the current year's activities with the previous year's. It is used for future planning.

RETENTION

Record copy: Permanent. May be transferred to State Archives, if information is not compiled in an aging and adult services annual report.

Duplicate copies: Retain for 1 year or until administrative need ends, whichever comes first and then destroy.

SUGGESTED PRIMARY DESIGNATION

Public.

(Approved 12/92)

SENIOR CENTER CLASS ROLLS (Item 19-15)

These forms record the participation of individuals in programs or activities held at senior centers. These activities include creative arts, transportation, income tax assistance, and health screenings. The rolls are used to compile monthly, quarterly, and annual reports. They include program or activity title, month and year, participant's name, date, and a check indicating whether person participated in activity or program.

RETENTION

Retain for 1 year after final payment on contract and then destroy.

SUGGESTED PRIMARY DESIGNATION

Exempt:45 CFR 1321.5 (2008).

(Approved 12/92)

SENIOR CENTER EMERGENCY CARDS (Item 19-16)

These are cards on all senior center members. They are used to contact senior center member's next of kin. They include member's name, address, birth date, telephone, whether they are a member, health information, name and telephone number of next of kin.

RETENTION

Retain for 1 year after participation ends and then destroy.

SUGGESTED PRIMARY DESIGNATION

Exempt:45 CFR 1321.51 (2008).

(Approved 12/92)

SENIOR CENTER MONTHLY FINANCIAL STATEMENT (Item 19-17)

This is a monthly financial statement submitted by senior centers to the county aging administrative office. It is used for accounting purposes. This statement includes center name, year, petty cash amount (current month, year-to-date), general account (class fees, center donations), less amount remitted to county, activity account, and total expenditures.

RETENTION

Record copy: Retain for 4 years after final payment on contract and then destroy, provided all audits have been completed and then destroy.

Duplicate copies: Retain until quarterly report submitted and then destroy.

SUGGESTED PRIMARY DESIGNATION

Public.

(Approved 12/92)

SENIOR CENTER WEEKLY MEAL REPORT (Item 19-18)

This is a report on meals served by all senior centers. It is compiled daily and submitted weekly to the local aging and adult services administrative office. The report is used to compile reports for the State Division of Aging and for future planning. It includes month and year, senior center's name, daily and weekly totals for congregate meals served, homebound meals received for participants over 60 years of age and spouses, staff, and volunteers for one meal or two meals a day, total meals served, total meals ordered, and amount of donations received for meals, ensure, coffee, and extra food, and total deposit, and accounts receivable for congregate meals.

RETENTION

Retain for 1 year after final payment on contract and then destroy.

SUGGESTED PRIMARY DESIGNATION

Public.

(Approved 12/92)

SENIOR CENTERS' MONTHLY REPORT (Item 19-19)

This is a monthly report on senior center activities. It is used to compile quarterly reports for the State Division of Aging Services. This report includes senior center name, date, actual service units provided, service (general category access service, in-home, community service, other services, meals, and transportation), year-to-date budget, actual budget, and current budget.

RETENTION

Record copy: Retain for 4 years after final payment on contract and then destroy, provided all audits have been completed later and then destroy.

Duplicate copies: Retain until quarterly report compiled and then destroy.

SUGGESTED PRIMARY DESIGNATION

Public.

(Approved 12/92)

SENIOR CENTERS' QUARTERLY REPORT (Item 19-20)

This is a quarterly report on all service units provided at senior centers. It is submitted to the aging and adult services administrative office and is used to compile reports for the State Division of Aging. This report includes senior center name, date, actual service units provided, service (general category access service, in-home, community service, other services, and transportation), year-to-date budget, actual budget, and current budget.

RETENTION

Record copy: Retain for 4 years after final payment has been made on contract and then destroy, provided all audits have been completed.

Duplicate copies: Retain until annual report compiled and then destroy.

SUGGESTED PRIMARY DESIGNATION

Public.

(Approved 12/92)

TITLE V PERSONNEL CASE FILES (Item 19-21)

These files document the participation of persons in the Senior Service Employment Program under 29 CFR 89 (1995). This program provides for the hiring of low-income persons over the age of fifty-five. The files include income certification form, client intake form, any related correspondence, and if applicable termination forms.

RETENTION

Retain for 4 years after client leaves the program and then destroy, provided all audits have been completed.

SUGGESTED PRIMARY DESIGNATION

Private.

(Approved 12/92)

TITLE V QUARTERLY REPORT (Item 19-22)

This is a quarterly report that is submitted to the U.S. Department of Health and Human Services on persons employed through the Senior Community Service Program. It includes the sponsor's name and address, month and year, program number, agreement number, subproject number, project period, number of enrolled positions established, unsubsidized placement goal, number of enrollees and enrollment levels, job inventory, categories indicating services to general community and services to elderly community, enrollee characteristics (sex, education, race/ethnic group, income, age), signature, date, and may include an attached narrative report.

RETENTION

Retain for 2 years after final payment on contract and then destroy.

SUGGESTED PRIMARY DESIGNATION

Public.

(Approved 12/92)

TITLE XX ELIGIBILITY DECLARATION (Item 19-24)

This form is completed by a service worker to determine whether an individual is eligible to receive services from the agency. It includes applicant's name, address, and social security number; reason for eligibility; birth date, income declaration, indication of action taken (open, close, redetermination), and applicant's and service worker's signatures.

RETENTION

Retain for 4 years after client leaves the program and then destroy, provided all audits have been completed.

SUGGESTED PRIMARY DESIGNATION

Private.

(Approved 12/92)

TITLE XX TRANSPORTATION PROVIDER SERVICE REPORT (Item 19-23)

This report is used to receive reimbursement from the federal government for provided transportation services. It includes service provider name and address, billing period, service category, contract number, name of clients provided transportation, eligibility code, service activity, number of service units, rate of reimbursements, reimbursement request, fee assessed, subtotals, grand totals, provider's signature, and date.

RETENTION

Retain for 4 years after final payment on contract has been made and then destroy, provided all audits have been completed.

SUGGESTED PRIMARY DESIGNATION

Private.

(Approved 12/92)

VAN DRIVER'S STATEMENT (Item 19-25)

This is a form signed by all senior center van drivers. It is used to inform the driver of all driving policies. The statement includes a listing of driving policies, general statement on van insurance information, comments on winter driving, driver's signature and date.

RETENTION

Retain for 1 year separation of employee and then destroy.

SUGGESTED PRIMARY DESIGNATION

Public.

(Approved 12/92)

VOLUNTEER CALENDAR (Item 19-26)

This calendar documents the scheduling of volunteers at the senior centers. It is a monthly calendar containing notations indicating volunteer's name and specific times scheduled to work at center.

RETENTION

Retain for 1 year and then destroy.

SUGGESTED PRIMARY DESIGNATION

Public.

(Approved 12/92)