Programed facilities (1) Newport-Day care facility and residential facility. Inventory and Programing Data (Instructions for completing form PHS-4774-1, inventory-general data, mental retardation facilities construction program) 1. Enter name or number of service area. From State file information, form A, obtain the following data 2. Enter the city or town, county, and name of facility, listing all facilities in each city or town consecutively in alphabetical order. 3. Check one: A-diagnostic/evaluation clinic; B-day facility; C-residential facility. 4-5. Enter type of ownership of property and sponsorship of programs within facility, using the following codes: 6. Enter interest program sponsor has in property, using the following codes: A-own; B-rent or lease; C-free use. From State file information, form B, obtain the following data 7. Enter number of buildings in facility by design classification in the following coded columns: A-originally designed as a facility for the mentally retarded. C-not designed or remodeled as a facility for the mentally retarded. 8. For the originally designed buildings (item 7A), enter in column 8a, the number suitable; and in column 8b, the number unsuitable on the basis of established criteria for structural adequacy. From State file information, form C, item 3, obtain the following data 9. Enter total number of different mentally retarded individuals served by the facility. 10. a, b, c, and d. Enter the number mentally retarded individuals served by level of retardation. 11. a, b, and c. Enter the number mentally retarded individuals served for each specified age group. (Instructions for completing form PHS-4774-2, inventory-service data, mental retardation facilities construction program) 1. Enter name or number of service area. 2. From State file information, form A, enter the city or town, county, and name of facility listing all facilities in each city or town consecutively in alphabetical order. From State file information, form C, obtain the following data 3. Enter caseload for diagnostic and evaluation clinic program. 4. In column 4a, enter the total number of persons served in the day facility program (see item 4(b) of form C). For columns 4b through 4f, enter the caseload for each of the specified services, as shown on form C, items 4b-1 through 4b-5. 5. In column 5a, enter the total number of persons served in the residential facility program (see item 4 (c) of form C). For columns 5b through 5f, enter the caseload for each of the specified services, as shown on form C, items 4c-1 through 4c-5. |