checked> 0 - No assistance needed —patient is independent or does not have needs in this area checked> 1 - Non-agency caregiver(s) currently provide assistance checked> 2 - Non-agency caregiver(s) need training/ supportive services to provide assistance checked> 3 - Non-agency caregiver(s) are not likely to provide assistance OR it is unclear if they will provide assistance checked> 4 - Assistance needed, but no non-agency caregiver(s) available checked> 0 - No assistance needed in this area checked> 1 - Caregiver(s) currently provide assistance checked> 2 - Caregiver(s) need training/ supportive services to provide assistance checked> 3 - Caregiver(s) not likely to provide assistance checked> 4 - Unclear if Caregiver(s) will provide assistance checked> 5 - Assistance needed, but no Caregiver(s) available

checked> 0 - No assistance needed —patient is independent or does not have needs in this area checked> 1 - Non-agency caregiver(s) currently provide assistance checked> 2 - Non-agency caregiver(s) need training/ supportive services to provide assistance checked> 3 - Non-agency caregiver(s) are not likely to provide assistance OR it is unclear if they will provide assistance checked> 4 - Assistance needed, but no non-agency caregiver(s) available checked> 0 - No assistance needed in this area checked> 1 - Caregiver(s) currently provide assistance checked> 2 - Caregiver(s) need training/ supportive services to provide assistance checked> 3 - Caregiver(s) not likely to provide assistance checked> 4 - Unclear if Caregiver(s) will provide assistance checked> 5 - Assistance needed, but no Caregiver(s) available

checked> 0 - No assistance needed —patient is independent or does not have needs in this area checked> 1 - Non-agency caregiver(s) currently provide assistance checked> 2 - Non-agency caregiver(s) need training/ supportive services to provide assistance checked> 3 - Non-agency caregiver(s) are not likely to provide assistance OR it is unclear if they will provide assistance checked> 4 - Assistance needed, but no non-agency caregiver(s) available checked> 0 - No assistance needed in this area checked> 1 - Caregiver(s) currently provide assistance checked> 2 - Caregiver(s) need training/ supportive services to provide assistance checked> 3 - Caregiver(s) not likely to provide assistance checked> 4 - Unclear if Caregiver(s) will provide assistance checked> 5 - Assistance needed, but no Caregiver(s) available

checked> 0 - No assistance needed —patient is independent or does not have needs in this area checked> 1 - Non-agency caregiver(s) currently provide assistance checked> 2 - Non-agency caregiver(s) need training/ supportive services to provide assistance checked> 3 - Non-agency caregiver(s) are not likely to provide assistance OR it is unclear if they will provide assistance checked> 4 - Assistance needed, but no non-agency caregiver(s) available checked> 0 - No assistance needed in this area checked> 1 - Caregiver(s) currently provide assistance checked> 2 - Caregiver(s) need training/ supportive services to provide assistance checked> 3 - Caregiver(s) not likely to provide assistance checked> 4 - Unclear if Caregiver(s) will provide assistance checked> 5 - Assistance needed, but no Caregiver(s) available

checked> 0 - No assistance needed —patient is independent or does not have needs in this area checked> 1 - Non-agency caregiver(s) currently provide assistance checked> 2 - Non-agency caregiver(s) need training/ supportive services to provide assistance checked> 3 - Non-agency caregiver(s) are not likely to provide assistance OR it is unclear if they will provide assistance checked> 4 - Assistance needed, but no non-agency caregiver(s) available checked> 0 - No assistance needed in this area checked> 1 - Caregiver(s) currently provide assistance checked> 2 - Caregiver(s) need training/ supportive services to provide assistance checked> 3 - Caregiver(s) not likely to provide assistance checked> 4 - Unclear if Caregiver(s) will provide assistance checked> 5 - Assistance needed, but no Caregiver(s) available

checked> 0 - No assistance needed —patient is independent or does not have needs in this area checked> 1 - Non-agency caregiver(s) currently provide assistance checked> 2 - Non-agency caregiver(s) need training/ supportive services to provide assistance checked> 3 - Non-agency caregiver(s) are not likely to provide assistance OR it is unclear if they will provide assistance checked> 4 - Assistance needed, but no non-agency caregiver(s) available checked> 0 - No assistance needed in this area checked> 1 - Caregiver(s) currently provide assistance checked> 2 - Caregiver(s) need training/ supportive services to provide assistance checked> 3 - Caregiver(s) not likely to provide assistance checked> 4 - Unclear if Caregiver(s) will provide assistance checked> 5 - Assistance needed, but no Caregiver(s) available

checked> 0 - No assistance needed —patient is independent or does not have needs in this area checked> 1 - Non-agency caregiver(s) currently provide assistance checked> 2 - Non-agency caregiver(s) need training/ supportive services to provide assistance checked> 3 - Non-agency caregiver(s) are not likely to provide assistance OR it is unclear if they will provide assistance checked> 4 - Assistance needed, but no non-agency caregiver(s) available checked> 0 - No assistance needed in this area checked> 1 - Caregiver(s) currently provide assistance checked> 2 - Caregiver(s) need training/ supportive services to provide assistance checked> 3 - Caregiver(s) not likely to provide assistance checked> 4 - Unclear if Caregiver(s) will provide assistance checked> 5 - Assistance needed, but no Caregiver(s) available