Division of Public Health
F-01949A (12/2016) / STATE OF WISCONSIN
TRIBAL ADRS ANNUAL UPDATE 2017
Tribal Name / Submission Date
Enter Tribal Name / Click here to enter a date. /
Completed by Name
Enter Name /
DIRECTIONS: Please review and submit the following documentation. This page serves as a checklist to ensure all requested information is provided. Attach all documentation to one email message and send to your Regional Quality Specialist, and the email box. Save and submit this document in its current format. Do not send as a pdf file.
- ADRC/Tribal ADRS Directory/Contact Information
☐Verify ADRS Information in SharePoint is accurate and update as needed:
- Organizational Structure
☐Attach Tribal Organization Chart which details:
- ADRS
- Aging Services
- Adult Protective Services/Elder Abuse/Adults at Risk
- Optional Services
☐Appendix B Optional Services
- Budget Information and Subcontract Information
☐Appendix C Annual Budget
- Tribal ADRS Success Stories
☐Appendix D Success Stories
Appendix A –ADRC/Tribal ADRS Directory
Click on the ADRC Directory tab in the SharePoint site. Review the ADRS contact information in the directory. If the information needs to be updated, click “edit.” Click on the specific column and enter the updated information. Click “stop editing this list” to save the changes.
Appendix B–Optional Services
Please select any of the following optional services that the Tribal ADRS plans to provide in 2017.
☐Resident Relocations
☐Short-Term Service Coordination
☐Prevention & Wellness
☐Long-Term Care Functional Screen (if certified)
☐Tribal Income Maintenance
☐Enrollment Counseling
☐Disenrollment Counseling
Appendix D- ADRSSuccess Stories from 2016
Use the space provided below.
1. / Please share a success story about a tribal member who received assistance as a result of collaboration between the Tribal ADRS and the ADRC. (Do not share name or other identifying information.)Click here to enter text. /
2. / Describe a successful marketing or outreach event that you participated in during the year.
Click here to enter text. /