Adult Care Facility
Chronological Admission and Discharge Register
NEW YORK STATE DEPARTMENT OF HEALTH
Adult Care Facility/Assisted Living
Facility Name
Period Covered
Operating Certificate Number
From
To
Page Number
Admission Codes*
1
2
3
4
5
6
7
8
9
–
–
–
–
–
–
–
–
–
Level of Care (LOC) Codes*
Hospital
Own Home
Skilled Nursing Facility (SNF)
Another Adult Home/Enriched Housing Program
State Development Center
State Psychiatric Center
Transfer from another unit of this facility
Death
Other (specify)
Date
of
Resident’s Name
DOH-5177 (DSS 3026) (12/15)
Age
AH
ALP
A
E
EHP
S
Sex
Admitted
From
Discharged
To
–
–
–
–
–
–
Adult Home
Assisted Living Program
Assisted Living Residence
Enhanced Assisted Living Residence
Enriched Housing Program (EHP)
Special Needs Assisted Living Residence
Facility and Address
Admitted From or Discharged To
LOC**