Output: / Period: / Year:
Part A: Residential Aged Care Services with High and Low Care Places
Residential Aged Care Services with High Care Places
High Care Places / Maximum Residents Possible / Residents(last day of the month) / Maximum Bed Days Possible / Resident Days
(during the month)
1 S1
2 S2
3 S3 (Exclude Respite Care)
4 S4
5 S5
6 S6 (Exclude Respite Care)
7 S7
8 S8
9 ACFI Residents (High)
10 ACFI Residents (Low)
Total ACFI Days (=9+10) / Calc
11 New Permanent Residents
12 Respite Care (High)
13 Respite Care (Low)
14 Total =(1 to13) / 0 / Calc / 0 / Calc
Residential Aged Care Services withLow Care Places
Low Care Places / Maximum Residents Possible / Residents(last day of the month) / Maximum Bed Days Possible / Resident Days
(during the month)
15 S1
16 S2
17 S3 (Exclude Respite Care)
18 S4
19 S5
20 S6 (Exclude Respite Care)
21 S7
22 S8
23 ACFI Residents (High)
24 ACFI Residents (Low)
Total ACFI Days (=23+24) / Calc
25 New Permanent Residents
26 Respite Care (High)
27 Respite Care (Low)
28 Total =(15 to 27) / 0 / Calc / 0 / Calc
Aged Care Service:
Output: / Period: / Year:
/ Completed
ACFI domain levels for all residents
Assessment Type / Assessment Level / Maximum Residents Possible / Residents
(last day of the month) / Maximum Bed Days Possible / Resident Days
(during the month)
29 ADL / High
30 ADL / Medium
31 ADL / Low
32 ADL / No payment
Total ADL Days / Calc
33 BEH / High
34 BEH / Medium
35 BEH / Low
36 BEH / No payment
Total BEH Days / Calc
37 CHC / High
38 CHC / Medium
39 CHC / Low
40 CHC / No payment
Total CHC Days / Calc
Supported Residents Ratios
41 Supported residents number and percentage achieved (Service) / Calc % / /
42 Supported residents number and percentage achieved (New) / Calc % / /
Respite Care allocation and usage: NB: See the AIMS manual for instructions when a service provides both Generic and Aged Persons Mental Health places / Resident Days
43 RC FY Allocation:
44 RC Usage (this month):
45 RC YTD Usage:
46 Percentage of Respite Care Days (allocation) achieved YTD / Calc
Incentive Payment
47 Period Start: / DD-MM-YYYY
48 Period End / DD-MM-YYYY
49 RRI Allocation
50 RRI Usage
51 RRI % Achieved / Calc
Agency Information Management System Form S5 115 Page 1 of 3Effective July 2011