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Senior Safety Program Application

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Personal Information

Applicant Name*

First Middle Last

Age (please enter a number)*

Date of Birth*

MM slash DD slash YYYY

Gender*

Male

Female

Other

What is your gender identity?*

Male

Female

Transgender-Male

Transgender-Female

Non-Binary

Non-Disclose

Other

Street Address*

Street Address City State ZIP Code

Mailing Address (if different)

Street Address Address Line 2 City State ZIP Code

County*

Reservation (if applicable)

Phone*

Phone Type

Home

Mobile

Work

Other

Email Address

How did you hear about this program?*

Brochure

Word of Mouth

Presentation

Doctor

Family

Friend

Are you working with a ND Assistive Consultant?*

Yes

If You are working with a ND Assistive Consultant please tell us who.

Demographic Information

What is your Ethnicity?*

Hispanic or Latino

Not Hispanic or Latino

Unknown

What is your race?*

American Indian/ Native Alaskan

Asian

Black/ African American

Native Hawaiian/ Other Pacific Islander

Non-Minority (White, non-Hispanic)

White-Hispanic

Other

What is your primary language?*

English

Other

Do you live alone?*

Yes

Unknown

Do you feel socially isolated?*

Yes

Are you currently enrolled in Medicare?*

Yes

Are you currently enrolled in Medicaid?*

Yes

Are you currently enrolled in Northland PACE?*

Yes

Priority Funding and Eligibility

Priority Funding Areas

Please note that funding for this program is a limited financial resource through the Older Americans Act. Preference will be given to those who fall within the priority funding areas first.

I live in a rural area (not Bismarck, Grand Forks, or Fargo)*

Yes

I am at risk of being placed in a skilled nursing facility*

Yes

Income Eligibility

Please review the chart below to determine if your income level is below the national poverty level.

**2022 HHS Poverty Guidelines**
Persons in Family/Household	Poverty Guideline
1	$13,590
2	$18,310
3	$23,030
4	$27,750
5	$32,470
6	$37,190
7	$41,910
8	$46,630
For each additional person, add:	$4,720

My income level is below the national poverty level (see chart above)*

Yes

Eligible Items

Alerting Devices for Hearing Loss
Anti-Elopement Devices such as Wandering Alarms
Bed Rails (limited options)
Caregiver Pager System
Emergency Response Systems (for Landline only)
Grab Bars (stainless steel only)
Handheld Shower Heads (one option)
Medication Dispensers and Reminders
Personal Hearing Amplifiers (Comfort Duett & Pocket Talker)
Portable Seat Lift
Shower Chairs (provide inside measurements of bathtub)
Adaptive Silverware
Toilet Safety Frames/Rails (limited options)
Toilet Seat Risers (limited options)
Tub Rails (limited options)
Tub Transfer Benches (provide inside measurements of bathtub)
Voice Amplifiers and Accessories

Devices Requested*

Please list the assistive safety devices you are requesting in order of importance. Please only put one device per line.

Please list any health concerns or disabilities that contribute to your need for the requested item(s).*

How did you determine what assistive technology was appropriate for your needs?*

(For example, My OT recommended. I received a device demonstration from an Assistive staff member.

Explain how this device(s) increases your safety/ independence on a day-to-day basis.*

If you are requesting a toilet seat riser, shower chair, bathtub transfer bench, grab bar, or bed transfer handle, please provide the following information:

Item

Height (feet)

(inches)

Weight

If you are requesting a toilet seat riser, which shape of toilet do you have?

Standard Round

Elongated

If requesting a shower chair, please check all that apply:

The shower chair needs a backrest.

The shower chair needs to have arms

If requesting a shower chair, what is the inside measurement of the bathtub or shower where the chair will be used?

If requesting a grab bar(s), please provide the length(s) and number of grab bars needed.

Standard, ADA-compliant grab bars are available in the following sizes: 12”, 16”, 18”, 24”, 30”, 32”, 36”, and 42”. Size needed is dependent on the space and the distance between studs (if installed horizontally).

Grab Bar Size

Number of Bars Needed

If requesting an emergency alerting system, do you have a landline?

Please note that the Senior Safety program only provides systems that require a landline.

Yes

Should the devices be shipped to your home?*

Yes

Please provide the address to which the devices should be shipped

Please note that not all vendors are able to ship to PO Boxes. Therefore, the street and mailing address should be provided.

Street Address Address Line 2 City State ZIP Code

Contact Information

Are you completing this form on behalf of someone, or would you prefer we contact someone other than yourself regarding your request?

Yes

Contact Name

First Last

Contact Relationship/Title

Contact Phone Number

Contact Phone Type

Home

Mobile

Work

Other

Contact Email Address

Questions?

Please call:
Toll-free: 1.800.895.4728
Mandan Local: 701.258.4728
Fargo Local: 701-365-4728

You may also email the Senior Safety Program at:
seniorsafety@ndassistive.org

This program is supported by funding from the United States Department of Health and Human Services, Administration for Community Living, Administration on Aging, and granted through the North Dakota Department of Human Services, Aging Services Division.

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This field is for validation purposes and should be left unchanged.

Senior Safety Program Application

Personal Information

Demographic Information

Priority Funding and Eligibility

Priority Funding Areas

Income Eligibility

Eligible Items

Contact Information

Questions?

Fargo, ND

1-800-895-4728

Bismarck, ND

1-800-895-4728

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