Bergen County New Jersey

Bergen County Division of Senior Services

Aging & Disability Resource Connection

MEALS ON WHEELS APPLICATION

Fax 201-336-7424 Tele. 201-336-7420

Date of Application

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Applicant language - If non-English speaking, indicate preferred language below

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Submitted by(*)

ApplicantOther (Indicate whom) Invalid Input

If "Other," indicate whom

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Applicant has agreed to accept MOW(*)

YesNo Invalid Input

Discharged from Hospital/Rehab within 30 days(*)

YesNo Invalid Input

There may be a waitlist for MOW, is someone able to assist you while you are waiting for MOW?(*)

Yes - limited assistanceNo support system Invalid Input

Last Name(*)

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First Name(*)

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MI

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Nickname or Preferred Name

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Address(*)

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Date of Birth (mm/dd/yyyy)(*)

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Weight:

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If other, please specify

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Apt/Floor

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Age

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Height:

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Directions to home (include cross st; access code to bldg,etc.)(*)

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City(*)

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Home Phone Number(*)

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Mobile Phone Number

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Primary Phone(*)

HomeMobile Invalid Input

Applicant Email

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Income (select one)(*)

$0 - $1,255 per month (One Person FPL – Federal Poverty Level) / $0 - $1,703 per month (2 persons, FPL – Federal Poverty Level)

$1,256 - $3,034 per month (One Person Between FPL & Elder Index) / $1,704 - $4,011 per month (2 persons Between FPL & Elder Index)

$3,035 per month or above (1 person) / $4,012 per month or above (2 persons)

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Emergency Contact Information (First of possible 2)

Name

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Relationship

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Town

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Discussion authorization

Authorize to discuss case with this contact Invalid Input

Emergency Contact 1 Email

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Telephone Number

Home

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Mobile

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Work

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Primary Phone

HomeMobileWork Invalid Input

Emergency Contact Information (Second of possible 2)

Name

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Relationship

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Town

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Discussion authorization

Authorize to discuss case with this contact Invalid Input

Emergency Contact 2 Email

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Home

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Mobile

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Work

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Primary Phone

HomeMobileWork Invalid Input

Physician Name

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Town

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Physician Phone

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I Authorize to discuss this case with this physician

YesNo Invalid Input

INSTRUMENTAL ACTIVITIES OF DAILY LIVING: In the last 7-days, if you’ve had some difficulty in performing any of the following tasks by yourself, or required personal or standby assistance, or supervision, check ‘impairment’.

1. Preparing Meals

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2. Ordinary Housework

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3. Laundry

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4. Shopping

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5. Managing Medicine

Impairment Invalid Input

6. Using Transportation

Impairment Invalid Input

7. Paying Bills / Managing Money

Impairment Invalid Input

8. Using the Telephone

Impairment Invalid Input

ACTIVITIES OF DAILY LIVING In the last 7 days, if you’ve had difficulty or required any help in performing the following, check ‘impairment’.

1. Bathing

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2. Dressing

Impairment Invalid Input

3. Eating

Impairment Invalid Input

4. Walking /Transferring

Impairment Invalid Input

5. Continence

Impairment Invalid Input

6. Toileting

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MALNUTRITION SCREENING

1. Have you recently lost weight without trying?(*)

NoYes Invalid Input

If yes, how much weight have you lost?(*)

2. Have you been eating poorly because of decreased appetite?(*)

NoYes Invalid Input

FOOD INSECURITY SCREENING

Do you wish to speak to a dietitian regarding your nutritional health?(*)

YesNo Invalid Input

The WELLNESS CHECK PROGRAM is an automated telephone reassurance program designed to check on the well-being of residents who live alone, are homebound, and over the age of 60, or age 18+ with a disability. Meals on Wheels participants are encouraged to enroll in this program.

Do you want to enroll to receive information about the Wellness Check Program? Invalid Input

Preferred Meal Plan (select one):(*)

Hot: One hot meal delivered each weekday Monday - Friday.Frozen: One week supply of five (5) frozen meals delivered on a scheduled day each week.(Frozen meals are fully cooked and can be reheated in a conventional or microwave oven.) Invalid Input

High risk clients only: Weekday delivery of two (2) frozen meals for use on the weekend. Invalid Input

INDIVIDUAL RESPONSIBILITY
- You must be home to accept your meal delivery and make contact with the driver. Your driver can not leave your meal without knowing that you are safe.
- Drivers must have safe access to your door including but not limited to proper restraint or confinement of all pets during delivery.
- If you have a doctors’ appointment or will not be home, you must temporarily suspend your meal delivery by calling Meals on Wheels no later than 12:00 noon the business day before. You can leave a message any time of the day, 7-days a week.
- If you do not hear the door and find an ‘Attempted to Deliver’ tag left by the driver, or receive a voice message, call Meals on Wheels immediately at
201-336-7420. If we do not hear from you, we will stop your meal delivery and may call the police to check on your well-being.
- Repeated failure to suspend your delivery or late suspension may result in termination from the program. Food is a valuable resource that we cannot waste. - A voluntary donation of $1.25 per meal is suggested. Please donate whatever you are able.
- We can only provide one meal a day, and we may not be able to deliver that meal as planned on any given day due to hazardous weather conditions or other unforeseen circumstances. You must keep food in your home at all times.
- Every 6-month a face-to-face assessment in your home is required to determine your eligibility to continue to receive home delivered meals and to provide possible referrals for other services to benefit you. A representative will contact you to schedule an appointment within a four--hour window. A family member or caregiver can be present if you wish.

(*)

By submission of this application, I certify that the information provided for my eligibility determination is correct to the best of my knowledge, and I understand and agree to the client responsibilities when accepting this service. Agree with the acknowledgement statement to submit the form.

I am not a robot(*)

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