Home > Senior Safety Program > Senior Safety Application Senior Safety Program Application "*" indicates required fields Step 1 of 4 25% Personal InformationApplicant 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 Applicant Street Address* Street Address City State North DakotaAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Mailing Address (if different) Street Address Address Line 2 City State North DakotaAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code County* Reservation (if applicable) Applicant Phone*Phone Type Home Mobile Work Other Applicant 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 No If You are working with a ND Assistive Consultant please tell us who. Demographic InformationWhat 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 No Unknown Do you feel socially isolated?* Yes No Are you currently enrolled in Medicare?* Yes No Are you currently enrolled in Medicaid?* Yes No Are you currently enrolled in Northland PACE?* Yes No Priority Funding and EligibilityPriority 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 No I am at risk of being placed in a skilled nursing facility* Yes No My income level is at or below the national poverty level (see chart above)* Yes No 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. Add RemovePlease 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:ItemHeight (feet)(inches)Weight Add RemoveIf 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 SizeNumber of Bars Needed Add RemoveIf 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 No Should the devices be shipped to your home?* Yes No If you want equipment shipped elsewhere, please provide the name and address to which the devices should be shippedPlease note that not all vendors are able to ship to PO Boxes. Therefore, the street and mailing address should be provided. Name Address City State North DakotaAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Contact InformationAre you completing this form on behalf of someone, or would you prefer we contact someone other than yourself regarding your request? Yes No Alternate Contact NameName of friend or family you would like us to contact instead. First Last Alternate Contact Relationship/Title Alternate Contact Phone NumberAlternate Contact Phone Type Home Mobile Work Other Alternate 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.PhoneThis field is for validation purposes and should be left unchanged.
