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LTCFS Instructions Module 3: LTCFS Basic Information, Screen Information, Demographics, and Living Situation

Glossary of Acronyms, P-01010 (PDF) | LTCFS Paper Form, F-00366 (PDF)


3.1 Overview

Demographic information collected for the LTCFS does not determine eligibility for long-term care services. Demographic information is used for two purposes:

  • The foundation of an enrollee’s full comprehensive assessment if the person chose to enroll in a long-term care program.
  • Quality assurance and program oversight by state and agency administrators.

3.2 Basic Information

Basic Screen Information

Screening Agency
This is a read-only field that is automatically entered by FSIA based on the agency selected by the screener after login.

Referral Date
This is a user entered field. The screener should follow agency or program policy for what date to use in this field.

Screen Type
This is selected after the screener selects the correct individual from the home page.

Screener Name and Screener ID
Select the screener name for the screener who completes the in-person assessment with the individual. The first time a screener’s name is selected the Screener ID field will need to be entered. The screener chooses what to enter in this field. One suggestion is to use the C####### number that the screener uses to log in to the UW-Oshkosh curriculum or into the Continuing Skills Test. Once the Screener ID has been entered for a screener, the system will remember it and the screener will only need to select the appropriate name. The screener can change the Screener ID at any time.

Applicant Information

“Applicant” is the person being screened as part of their application (or rescreen) for Family Care, Family Care Partnership, PACE, or IRIS. These selections need to correlate with Social Security Administration (SSA) information. Therefore, the information the screener enters must match Social Security. This ensures that FSIA, CARES, and ForwardHealth are using the same name, date of birth, Social Security number (SSN), and gender criteria.

Enter the name as it is on file with SSA. If the person prefers to be called by a different name, include this in the Notes section.

The selection of Male or Female should match SSA. If the person’s gender identity is different from SSA, include this in the Notes section.

Birth Date
Enter the applicant’s date of birth in MM/DD/YYYY, as in 01/01/1950. LTCFS programming will not allow dates to be entered that make the applicant more than 150 years old or younger than 17 years, six months.

Social Security Number
Enter the applicant’s SSN. If a Pseudo SSN is used, it will prevent enrollment into ForwardHealth. After the SSN is initially entered and saved on the LTCFS, only the four last digits of the SSN will display in FSIA and on all screen reports. If the screener needs to change or confirm the accuracy of the SSN, they may select the View/Edit box in FSIA to temporarily display and/or edit the SSN. After leaving the page, the SSN will again be obscured.

The screener should review the individual’s name, date of birth, and SSN based on documentation such as a state-issued ID, driver’s license, or Social Security card. If an inconsistency is noted, the screener can try and update those items in the screen, but if there is an error message, the screener should contact the DHS SOS Help Desk. When there is an issue with matching the Master Client Index (MCI number) or choosing the correct applicant and an error occurs, a correction is needed. The screener should first consult the  Basic Information for Screeners, P-01604 (PDF) and if the error cannot be resolved through that reference, then the screener should contact the DHS SOS Help Desk by emailing or calling 608-266-9198 for assistance.

Address, City, State, Zip Code, Phone Number
Enter the applicant's “permanent residence” address. If the person is currently residing in a facility (for example, a nursing home or community-based residential facility), the facility may or may not be their “permanent residence.” If a person is currently residing in a nursing home but maintains their apartment in the community with the intention of returning home in the next few weeks, the apartment would be the permanent residence, not the nursing home. Use your professional discretion to determine the applicant's permanent residence.

Include street number, street name, apartment number, city, and zip code. Include phone number if available.

For transient persons, enter the address they lived at the most in the last six months.

County of Residence and County or Tribe of Responsibility
Select the appropriate county or tribe from the drop-down menu. In most cases, these will be the same. In a few instances, a person may live in one county, but another county or tribe is responsible for services, costs, and protective services. For the purposes of screening, residency is determined by physical presence or the intent to reside, not a temporary living situation. 

This space is available for the screener to enter directions to the individual's home. Keep entries brief and succinct. 

3.3 Screen Information

Source of Information

Referral Source
Select from the drop-down menu who contacted the screening agency to refer this person for a functional screen. This is required for initial screens. If the screen is being completed as an annual or change in condition screen, this selection is optional. If “Other” is selected, enter the source of the referral in the text box provided.

Primary Source for Screen Information
Select the primary source for screen information from the drop-down menu. If the primary source is not listed, select “Other” and enter the source of information in the text box provided.

In most cases, the primary source for screen information should be the individual. Often, screeners will also need to have collateral contacts with family, residential staff, and health care providers.

In some instances, information will be obtained almost equally from multiple sources. “Primary” means the majority (over 50%). Select the source that seems most accurate.

If the individual uses an interpreter, the individual—not the interpreter—is still the primary source of information.

If the applicant could participate in the screening process, the applicant should participate to the greatest extent possible. This question is meant as a quality assurance reminder that screeners must not complete a screen by only talking with caregivers, staff, or other collateral contacts. If the individual is not the primary source of information, it is expected that in most cases other parts of the screen will indicate significant cognitive limitations.

Location Where Screen Interview Was Conducted
Select the place where the screen was conducted from the drop-down menu.

“Person's current residence” is selected when the individual is screened in the individual’s permanent residence and not a temporary living situation.

“Temporary residence (non-institutional)” is selected when the individual being screened is staying with family or friends temporarily, for instance to recuperate from an illness or surgery. It also includes temporary stays in residential facilities, such as respite in a community-based residential facility (CBRF).

“Nursing home” is selected when the individual being screened is temporarily living in a skilled nursing facility, intermediate care facility for individuals with intellectual disabilities (ICF-IIDs) or facility for persons with developmental disabilities (FDDs).

“Hospital” is selected when the individual is screened while in the hospital.

“Agency Office/Resource Center” is selected when the individual is screened in the agency office or resource center.

“Other” is selected when the individual is screened somewhere other than those listed above, such as correctional facility, local library, or restaurant. Enter a description in the text box.

HCB Waiver Group Information

This screen item should only be completed by the ADRC or Tribal ADRS and only for an individual pursuing participation in IRIS, otherwise this should be left blank.

The ADRC or Tribal ADRS selects the IRIS consultant agency (ICA) that the individual is interested in enrolling in from the drop-down menu in the HCB Waiver Group Information. This allows that specific ICA to view the LTCFS for that person to assess that person’s needs and to plan for potential enrollment of the person in the ICA.

This field defaults to blank when a rescreen or transfer is completed.

3.4 Demographics

Medical Insurance Information

Medical Insurance
Select all types of insurance coverage that the individual currently has.

If the person has Medicare coverage, VA benefits, or Railroad Retirement insurance, selecting the checkbox will “activate” the policy number field in FSIA. For purpose of the screen, it is not necessary to enter information in these fields.

Private insurance includes employer-sponsored insurances available as a job benefit.

When a person has Medicaid coverage, the MCI number will be automatically entered in FSIA when the Medicaid box is selected. 

Ethnicity and Race Information

Any selections made should be based on how the individual self-identifies. For purposes of the LTCFS at the initial screen if the individual chooses not to answer, leave the selection blank. At rescreen, if the individual requests to have this selection changed, the screener should make the change.

The Ethnicity selections include Hispanic or Latino and Not Hispanic or Latino.

The Race selections include (select all that apply):

  • American Indian or Alaska Native
  • Asian
  • Black or African American
  • Native Hawaiian or Other Pacific Islander
  • White
  • Other (describe in Notes section, if applicable)

Interpreter Information

If Language Interpreter is Required
Screeners should utilize interpreters when they are needed. This information will help long-term care programs better serve non-English speaking individuals.

Select the appropriate language if an interpreter is needed for the individual being screened. If the screener selects “Other,” record in the text box provided.

Leave this box unselected if no interpreter is needed for the individual being screened, comment in the Notes section if an interpreter is needed to communicate with caregivers.

Contact Information

For each contact person the individual wants to include, select the appropriate contact category. If the person meets more than one contact category, the screener should select the category that may have a legal role. The screener should refer questions about the legal role(s) of a contact person to their program oversight representative.

The contact categories to select from include:

  • Adult child
  • Ex-spouse
  • Guardian of person
  • Parent or stepparent
  • Power of Attorney
  • Sibling
  • Spouse
  • Other

Provide the contact’s information that is available. Any additional information, such as email address, best time to reach, best number to call, if power of attorney is activated, should be provided in the Notes section.

If “Other” is selected, enter a brief description in the text box provided.

If there are multiple contacts for the person, the screener can select Add New and enter in the additional contact’s name and address in the new “Contact Information” section.

3.5 Living Situation

Living Situation Information

Current Residence
This selection should be the individual’s permanent residence and not a temporary living situation, such as a motel, hospital, or rehabilitation facility. Select “Other” if none of the provided selections is appropriate and record an explanation in the text box. Most living situations fit into one of the options provided. If needed, the screener should provide additional information or clarification regarding the living arrangement in the Notes section.

Own Home or Apartment
This is a residence where the individual owns or is listed on the lease. The individual may or may not receive services. Selections include:

  • Alone
  • With Spouse/Partner/Family
  • With Non-relative/Roommates (this can include typical roommate situations as well as dorms, convents, or other communal settings)
  • With Live-in Paid Caregiver(s) (this includes service in exchange for room and board)

Someone Else’s Home or Apartment
This is a residence where the home is owned or rented by another person or entity, and the individual is not listed on the lease. Selections include:

  • Family (this includes adult children living with family)
  • Non-relative
  • Certified Adult Family Home (1-2 bed AFH) or other paid caregiver’s home
  • Home or Apartment for which the lease is held by support services provider

Apartment with Onsite Services
This is a residence that is an apartment facility, licensed by the state, where limited support and services are provided as part of the cost of residing there. Selections include:

  • Residential Care Apartment Complex (RCAC)
  • Independent Apartment Community-Based Residential Facility (CBRF)

Group Residential Care setting
This is a residence that is a home or facility licensed by the state where paid staff are available to support individuals 24/7. Selections include:

  • Licensed Adult Family Home (3-4 bed AFH)
  • CBRF 1-20 Beds
  • CBRF more than 20 beds
  • Children’s Group Home

Health Care Facility/Institution
This is a residence that is licensed by the state and provides intensive support and services for individuals with specific disabilities. Selections include:

  • Nursing Home (this includes a rehabilitation facility if licensed as a nursing home)
  • Facilities for Persons with Developmental Disabilities/Intermediate Care Facility for Individuals with Intellectual Disabilities (FDD/ICF-IID)
  • Developmental Disability (DD) Center/State Institution for Developmental Disabilities
  • Mental Health Institute/State Psychiatric Institution
  • Other Institute for Mental Disease (IMD)
  • Child Caring Institution
  • Hospice Care Facility

Do not select a health care facility or institution for an individual who is temporarily in one of these types of facilities and continues to maintain a residence elsewhere.

No Permanent Residence
This should be selected for an individual who does not have a permanent address. This could be residing in a homeless shelter or temporarily using a hotel or motel as their residence.

This should be selected for an individual whose current residence does not match any of the above selections. This could be a correctional facility. Do not select “Other” for someone in a hospital, swing bed, or other temporary living situation.

Prefers to Live
The "Prefers to Live" question is to be completed based on the individual’s informed preference, not what is deemed realistic, possible, or safest. The question should be based on where the person prefers to live in the long term, not short-term and, not where anyone else, including a guardian, wants the person to live. Screeners must take the time to explain the individual's options. The individual cannot express a preference if the screener has not informed them of their options first. The screener should use the definitions in Current Residence to select the appropriate option from the drop-down menu.

The drop-down selections are:

  • Stay at current residence
  • Move to their own home or apartment
  • Move to someone else’s home or apartment
  • Move to an apartment with onsite services
  • Move to a group residential care setting
  • Move to a health care facility or institution
  • No permanent residence
  • Unsure or unable to determine person’s preference for living arrangement

An individual's preference may be difficult to decipher, as the individual requesting or receiving services may acquiesce to whatever they feel limited to or whatever they have been told. Screeners are to use their best interviewing skills to select the most accurate answer, for example, individuals with intellectual/developmental disabilities often think or are told “group home” is the only option available to them, or an elderly individual may say they “belong in” a nursing home because they would be too much of a bother anywhere else.

Select “Unsure or unable to determine person's preference for living arrangement” if the person cannot comprehend their options and/or cannot communicate their preference.

Guardian or Family’s Preference for this Individual
This question captures the guardian or family member preference. The screener should use the definitions in Current Residence to select the appropriate option from the drop-down menu.

The drop-down selections are:

  • Not applicable
  • Stay at current residence
  • Move to their own home or apartment
  • Move to someone else’s home or apartment
  • Move to an apartment with onsite services
  • Move to a group residential care setting
  • Move to a health care facility or institution
  • No consensus among multiple parties
  • No response or no preference from guardian or family


Last revised March 28, 2024