Home Delivered Meals Quarterly Eligibility Re-Assessment        Circle one:    Q2  Q3  Q4

Client Name: _____________________________Date____________Done by___________________   

Address / Phone/ Emergency Contact:  	No change   		Change
Change to:
________________________________________			___________________________________
________________________________________			___________________________________

Yes  No     Does the person drive or go out for more than doctor appointments or occasional accompanied outing?
Yes  No     Is the person able to shop, prepare & pay for nutritious meals? 
Yes  No     Are there other people in the household who are willing and physically capable of preparing meals?
	
□	The participant is no longer eligible for HDM delivery because:     ________________________________________________________________________________________________________________________________________________________________________________
			Date of meal service is discontinued ______________________________ 
			Follow-up:  C1     family      another agency_________________________ 

□	If the answer to any of the above was Yes, the participant may not be eligible for HDM unless otherwise noted here:______________________________________________________________
         _______________________________________________________________________________
Comments: ________________________________________________________________________________________________________________________________________________________________________________________________

                                 Home Delivered Meals Quarterly Eligibility Re-Assessment        Circle one:    Q2  Q3  Q4

Client Name: _____________________________Date____________Done by___________________   

Address / Phone/ Emergency Contact:  	No change   		Change
Change to:
________________________________________			___________________________________
________________________________________			___________________________________

Yes  No     Does the person drive or go out for more than doctor appointments or occasional accompanied outing?
Yes  No     Is the person able to shop, prepare & pay for nutritious meals? 
Yes  No     Are there other people in the household who are willing and physically capable of preparing meals?
	
□	The participant is no longer eligible for HDM delivery because:     ________________________________________________________________________________________________________________________________________________________________________________
			Date of meal discontinuance ______________________________ 
			Follow-up:  C1     family      another agency_________________________ 

□	If the answer to any of the above was Yes, the participant may not be eligible for HDM unless otherwise noted here:_____________________________________________________________________
         ______________________________________________________________________________________
Comments: ________________________________________________________________________________________________________________________________________________________________________________________________
														Rev 10-11