Meals on Wheels ApplicationHome / Meals on Wheels Application Step 1 of 3 33% Date of application(Required) MM slash DD slash YYYY Submitted by(Required) Applicant Other Applicant language – If non-English speaking, indicate preferred language belowOtherApplicant has agreed to accept Meals on Wheels(Required) Yes No Discharged from Hospital/Rehab within 30 days(Required) Yes No There may be a waitlist for MOW, is someone able to assist you while you are waiting for MOW?(Required) Yes – limited assistance No support system Homebound Status Unable to leave home without assistance Able to leave home independently Health Reason for applying to MOW(Required)Health Issues Hard of Hearing Visually Impaired Oxygen User Non-ambulatory Wheelchair User Walker/Cane User (Select all that Apply)Dementia/Memory Impairment?(Required) Yes No Diet(Required) Regular / Heart Healthy / No added salt Special Diet Special diets are not availableLiving Arrangement Live alone Female Head of household With spouse/domestic partner/civil union With roommate/friend/family or other informal caregiver Caregiver is not home during the day Caregiver is home during the day Applicant is caring for a disabled child (select all that apply)Do you have a home health aide?(Required) Yes No Number of Hours of daytime careNumber of Hours of daytime careDo you receive Medicaid?(Required) Yes No Do you receive Managed Long-Term Support Services (MLTSS)?(Required) Yes No Last Name(Required)First Name(Required)MINickname or Preferred NameAddress(Required)Apt/FloorCity(Required)Date of Birth(Required) MM slash DD slash YYYY AgeWeightHeightDriver Instructions Hard of Hearing Visually Impaired Oxygen User Non-ambulatory Wheelchair User Walker/Cane User Other (Select all that Apply)Please specifyHome Phone Number(Required)Mobile Phone NumberApplicant Email Directions to home (include cross st; access code to bldg,etc.)Ethnicity(Required) Hispanic/Latino Non-Hispanic/Latino Race(Required) American Indian/Alaskan Native Asian Black/African American Pacific Islander/Native Hawaiian White Other Condition Frail Vulnerable Sex/Gender(Required) Male Female Intersex Transgender Other Sexual Orientation (optional) Heterosexual/Straight Lesbian/Gay Bisexual Unsure If not listed above please specify Other Veteran of US Armed Service(Required) Yes No Income(Required) $0. – $1,255. Month (1 person household) / $0.00 – $1,703. Month (2 persons, FPL) $1,256. – $3,034. Month (1 person, Elder Index) / $1,704.- $4,011. Month (2 persons, Elder Index) $3,035. – Month or above (1 person) / $4,012. – Month or above (2 persons) Emergency Contact InformationNameRelationshipHome TelephoneMobileWorkPrimary Phone Home Mobile Work TownDiscussion authorization Authorize to discuss case with this contact Emergency Contact Information 2NameRelationshipHome TelephoneMobileWorkPrimary Phone Home Mobile Work TownDiscussion authorization Authorize to discuss case with this contact Physician NamePhysician PhoneTownI Authorize to discuss this case with this physician Yes No 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 Impairment 5. Managing Medicine Impairment 2. Ordinary Housework Impairment 6. Using Transportation Impairment 3. Laundry Impairment 7. Paying Bills / Managing Money Impairment 4. Shopping Impairment 8. Using the Telephone Impairment 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 Impairment 4. Walking /Transferring Impairment 2. Dressing Impairment 5. Continence Impairment 3. Eating Impairment 6. Toileting Impairment MALNUTRITION SCREENING1. Have you recently lost weight without trying?(Required) No Yes If yes, how much weight have you lost?(Required) 2 – 13 lbs 14 – 23 lbs 24 – 33 lbs 34 lbs. or more Unsure 2. Have you been eating poorly because of decreased appetite?(Required) No Yes FOOD INSECURITY SCREENING1. In the past twelve months, have you worried about whether your food would run out before you had money to purchase more?(Required) Never Sometimes Often 2. In the past twelve months, my food didn’t last, and I didn’t have the money to purchase more.(Required) Never Sometimes Often NUTRITION SCREENING – The warning signs of poor nutritional health are often overlooked. This survey will help identify if you are at nutritional risk. Read the statements below. Check the appropriate column.3. Do you eat fewer than 2 meals a day?(Required) Yes No 4. Do you eat alone most of the time?(Required) Yes No 5. Do you eat fewer than 2 servings of milk or milk products a day?(Required) Yes No 6. Do you eat fewer than 5 servings of fruits and/or vegetables a day?(Required) Yes No 7. Do you have 3 or more drinks of beer, liquor, or wine almost every day?(Required) Yes No 8. Without wanting to, have you lost or gained weight in the last 6 months?(Required) Yes No 9. Do you have an illness or health condition that made you change the kind or amount of food that you eat? (Ex: Diabetes, Heart Disease, Kidney Disease, etc.)(Required) Yes No 10. Do you take 3 or more prescribed or over the counter drugs a day?(Required) Yes No 11. Are you unable to physically shop, cook, and/or feed yourself, or get someone to do it for you?(Required) Yes No 12. Do you have a problem with your teeth or mouth that makes it hard to eat?(Required) Yes No 13. Do you sometimes run out of money to buy food?(Required) Yes No Do you wish to speak to a dietitian regarding your nutritional health? Yes No 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? Preferred Meal Plan (select one):(Required) 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.) High risk clients only Weekday delivery of two (2) frozen meals for use on the weekend. Frozen meals are fully cooked and can be reheated in a conventional or microwave oven. 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 months, 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. Consent(Required) 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.(Required)CAPTCHA
