RESIDENT EXIT CHECKLIST (Form-0006)
Name
Block
Room No.
Date of notice given
/
Month
/
Day
Year
Date of exit
/
Month
/
Day
Year
Checklist
Yes
No
N/A
Room inspected
Key & Door Identification returned
Funds / personal papers returned
Receipt received for funds given
Final pharmacy account given
Pharmacy account paid
Public Trust notified if required
All medication returned
Medication signed for
Pension card returned
Medicare card returned
Tobacco / Cigarettes returned
Head Office informed
Final account given
Final account paid
Receipt given
Residents file, filed in "Exit Cabinet"
Mark as "Inactive" in Brevity
Forwarding Address
Bank Account Details
Account Name
BSB Number
Account Number
Residents/Family signature
Date
/
Month
/
Day
Year
Date
Staff Member's Name
Signature
Date
/
Month
/
Day
Year
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Submit
Should be Empty: