Take this form to 4 - FA

OT / PT Therapist

Dear Applicant:
All prospective residents must be able to live
independently upon acceptance into the retirement
home. The Functional Assessment evaluates the
candidate’s Activities of Daily Living (ADL’s). The
attached assessment must be completed by a
LICENSED OCCUPATIONAL THERAPIST (OT) or a
PHYSICAL THERAPIST (PT) not a physician, nurse,
corpsman or other health care professional. If you have
questions regarding this assessment, please contact
the Public Affairs Office.
Thank you
AFRH

RETURN ASSESSMENT TO:

ARMED FORCES RETIREMENT HOME
PUBLIC AFFAIRS OFFICE #584
3700 NORTH CAPITOL ST, NW
Washington, DC 20011-8400
Fax Number: (202) 541-7519
FUNCTIONAL Telephone: (800) 422-9988 opt. 1

ASSESSMENT
If FAXING documents to AFRH, please make a black
& white copy before sending the fax so that it will
be legible when it arrives. Please call and let us
know to look for the documents to come through
as well – Thank you for your help! We want to
prevent any delays in processing applications.

Cover Page FA 03-2019

Prior Versions No Longer Valid
PRIVACY ACT STATEMENT

AUTHORITY: 10 U.S.C 136, Under Secretary of Personnel and Readiness; 24 U.S.C. 401, Armed Forces Retirement
Home; DoD Directive 5124.09 Assistant Secretary of Defense for Personnel and Readiness Force Management;
DoD Instruction 1000.28, Armed Forces Retirement Home (AFRH); and E.O. 9397 (SSN), as amended.

PURPOSE: To determine and verify eligibility for admission to the AFRH.

ROUTINE USE(S): In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act
of 1974, as amended, the records contained herein may specifically be disclosed outside the DoD as a routine
use pursuant to 5 U.S.C. 552a(b)(3) as follows: To the Federal Reserve for processing the debt on the resident
account; To authorized contractors or vendors for the purpose of providing medical services to the residents of
the Armed Forces Retirement Home; To any Federal agency which provides medical services to residents of the
Armed Forces Retirement home; To the Inspector General of the Department of Defense or his/her designee,
for conducting inspections of AFRH records; To a Federal agency, or an organization or person contracting with
the AFRH for information needed in the performance of official duties related to reconciling or reconstructing
data files, compiling descriptive statistics, and/or making analytical or financial studies to support the function
for which the records were collected and maintained; Law Enforcement Routine Use; Congressional Inquiries
Disclosure Routine Use; Disclosure of Information to the National Archives and Records Administration Routine
Use; Disclosure to the Merit Systems Protection Board Routine Use; and Data Breach Remediation Purposes
Routine Use.

The applicable system of records notice is DPR 38 DoD, Armed Forces Retirement Home electronic Resident
Information System (eRIS) and is available at: (ADD LINK WHEN PUBLISHED).

DISCLOSURE: Voluntary; however, failure to provide the required information may result in the delay or denial
of admission.

Cover Page FA 03-2019

Prior Versions No Longer Valid
 ARMED FORCES RETIREMENT HOME
4 - FA
Functional Assessment
Form Completed by a Licensed Occupational or Physical Therapist

___________________ ___________________ ____ _________

Last Name First Name MI Birthdate

___________________ ___________________ ____ _________

Street Address City State Zip Code

This assessment is required for all applicants seeking admission to the Armed Forces Retirement Home and must be completed and
signed ONLY by a licensed occupational or physical therapist: NOT by a doctor, nurse, or other healthcare practitioner, or the
resident candidate. Please answer the following questions based on your professional judgment, observation and functional tests
administered during the applicant’s visit and initial each page of the assessment. Answers are subject for verification for accuracy
purposes and all “Yes” answers need to be explained. “Yes” answers may or may not affect you application approval.
The following responses are to be completed by a LICENSED PHYSICAL THERAPIST or OCCUPATIONAL THERAPIST only. Provider please
give a full explanation of ANY positive response to the following:
1. Requires and/or receives assistance using the telephone? (Such as: dialing, receiving, calling 911)
_____________________________________________________________________________________________
_____________________________________________________________________________________________ Yes No
_____________________________________________________________________________________________
_____________________________________________________________________________________________
2. Requires and/or receives assistance with transportation? (such as: planning, driving, bus, plane, taxi usage)
_____________________________________________________________________________________________
_____________________________________________________________________________________________ Yes No
_____________________________________________________________________________________________
_____________________________________________________________________________________________

3. Requires and/or receives assistance on incline, decline, or curbs?

_____________________________________________________________________________________________
_____________________________________________________________________________________________ Yes No
_____________________________________________________________________________________________
_____________________________________________________________________________________________
4. Requires and/or receives assistance shopping? (Such as: clothes, hygiene, grooming products)
_____________________________________________________________________________________________
_____________________________________________________________________________________________ Yes No
_____________________________________________________________________________________________
_____________________________________________________________________________________________
5. Requires and/or receives assistance to recall current events, locations, dates, or names?
_____________________________________________________________________________________________
_____________________________________________________________________________________________ Yes No
_____________________________________________________________________________________________
_____________________________________________________________________________________________

Page 1 of 4 FA 03-2019
OT/PT please initial EACH page: Prior Versions No Longer Valid
 ARMED FORCES RETIREMENT HOME
4 - FA
Functional Assessment
Form Completed by a Licensed Occupational or Physical Therapist

___________________ ___________________ ____ _________

Last Name First Name MI Birthdate

___________________ ___________________ ____ _________

Street Address City State Zip Code

6. Requires and/or receives assistance with meals? (i.e. feeding, carrying tray, diet management)
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Yes No
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
7. Requires and/or receives assistance with maintaining/cleaning living quarters and personal laundry?
(Such as: sweeping/vacuuming, making bed, cleaning bathroom, washing garments)
_____________________________________________________________________________________________
Yes No _____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
8. Requires and/or receives assistance with personal hygiene? (Such as: bathing, grooming, dressing)
Please indicate specific needs such as a grab bar, bath stool, supervision, or otherwise.
_____________________________________________________________________________________________
Yes No
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
9. Requires and/or receives therapy services? (to address weight, pain, cognition, ADL, wound care)
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Yes No
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
10. Requires and/or receives assistance of a mobility device? (Such as: wheelchair, person, cane, walker, etc.)
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Yes No
_____________________________________________________________________________________________
_____________________________________________________________________________________________

Page 2 of 4 FA 03-2019
OT/PT please initial EACH page: Prior Versions No Longer Valid
 ARMED FORCES RETIREMENT HOME
4 - FA
Functional Assessment
Form Completed by a Licensed Occupational or Physical Therapist

___________________ ___________________ ____ _________

Last Name First Name MI Birthdate

___________________ ___________________ ____ _________

Street Address City State Zip Code

11. Requires and/or receives assistance with toileting? (i.e. transfer, removing/reapplying clothes) If so, describe
any specific requirements or equipment necessary (colostomy, ileostomy, catheter, raised toilet seat, grab
bar, bed pan, incontinent supplies, etc.)
_____________________________________________________________________________________________ Yes No
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
12. Requires and/or receives assistance with transfers? (From chair, bed, bath, vehicle, etc.)
_____________________________________________________________________________________________
_____________________________________________________________________________________________ Yes No
_____________________________________________________________________________________________
_____________________________________________________________________________________________
13. Requires and/or receives assistance for daily decision making? (Such as: cues, supervision) If so, describe
cognitive abilities and limitations.
_____________________________________________________________________________________________
Yes No
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
14. Does the individual have difficulty walking distances over 50 feet (with or without resting periods)?
Please indicated the Furthest Distance walked during this session: (Select One)
Yes No
Over 150 Feet 26-50 Feet Less than 10 Feet

51-149 Feet 10-25 Feet Unable to Walk

15. Was there any walking support used during this demonstration: (If so, select all that apply)

Cane / Walker / Crutches Parallel Bars Oxygen / Breathing Equipment

Yes No
Prosthesis Seeing Eye Dog 1-2 persons assisting

Leaning on something in area Other: ____________________________________________________

16. Requires and/or uses mobility devices on a regular basis: (select all that apply)

Wheelchair (manual) Raised Toilet Seat Escort

Yes No
Powered Wheelchair / Scooter Shower chair / Bathing Stool Grab Bars

Cane / Walker / Crutches Powered Recliner / Lifting Chair Other: _____________________

Page 3 of 4 FA 03-2019
OT/PT please initial EACH page: Prior Versions No Longer Valid
 ARMED FORCES RETIREMENT HOME
4 - FA
Functional Assessment
Form Completed by a Licensed Occupational or Physical Therapist

___________________ ___________________ ____ _________

Last Name First Name MI Birthdate

___________________ ___________________ ____ _________

Street Address City State Zip Code

17. Requires assistance and/or experiences falls when transferring from mobility device to toilet, bed, bath, etc.?
_____________________________________________________________________________________________
Yes No
_____________________________________________________________________________________________
_____________________________________________________________________________________________
18. Requires and/or currently lives in a situation where some assistance is provided (within past 6 months)?
Select the living situation/s which best describes the individual’s recent accommodations:

Independent Living Situations: Living Situations with some assistance given:

Homeowner (House, Condo, etc.) At Home, with some aid from Family or Caretaker
Yes No
Renting or Leasing (Apartment, etc.) Receiving Home Health Care in Home/Apartment

Independent Senior (over 50) Living Community Assisted Living Facility

Independent – Traveling, RV, or Nomadic Lifestyle Nursing Home
Other: ___________________________________ Other: ___________________________________
19. Does this person currently with a family member or somebody else? If so, with whom (response is optional)?
Lives Alone Lives with Family or Spouse Lives with a roommate or friend
Yes No Name: __________________________________________________________________________________
Relationship: __________________________________________________________________________________

20. Who participated in this assessment?

Applicant Family Member Significant Other / Spouse

Caretaker Friend Other: _____________________

Your signature below indicates that you have assessed this individual and the answers to the questions are
accurate based on your professional judgement as a LICENSED OCCUPATIONAL OR PHYSICAL THERAPIST
Please Print (Stamp is acceptable) Signature and License Number Required
Therapist Name
Title:
Street Address Signature Date
City, ST ZIP Occupational Therapist Physical Therapist

Phone Number
Fax Number
License Number State

END
Page 4 of 4 FA 03-2019
OT/PT please initial EACH page: Prior Versions No Longer Valid