Form #7

State of New Jersey
Department of Human services
Division of Developmental Disabilities

I hereby consent to any and all medical or surgical treatment, including hospital admission, examinations and diagnostic procedures, anesthetics, transfusions and operations, which, in the event of an emergency are deemed necessary by competent medical clinicians to save the life or preserve the health of the above named individual. I also approve the release from the case records of any medical history or other medical data, which would be necessary for the physician and/or hospital to administer the treatment.

It is understood that general consent is only applicable specifically and exclusively to emergency situations. In each and every other instance of elective medical and/or surgical treatment recommended by medical professionals, an explicit, individual consent must be requested within a reasonable advance time period.

Emergency treatment should be followed by prompt notification of the guardian by the person(s) responsible for care of the individual.

Komninos' Law requires all parents or guardians to be notified of certain types of incidents within 2 hours.

As per the law, Hearten LLC will notify you within two hours of any major, moderate or minor physical injury related to incidents or allegations of abuse, neglect or exploitation.

In addition, Hearten LLC will notify you within two hours of any minor, moderate or major injury regardless of the cause unless you choose not to be notified.

The Parent / Guardian Roster will be a list of parents and guardians of individuals served and their contact information.

This list will be shared with those parents or guardians who choose to participate. You may choose to share your telephone number, email, or both.

If yes, please note your contact information:

If at any time you choose to change your preferences please notify us in writing.

I acknowledge that I have received, reviewed, and understand the Attendance, Absence, Arrival, and Early Exit Policy for Hearten Day Habilitation. I understand that consistent attendance, timely arrival, and full participation are required to ensure participant safety, continuity of services, appropriate staffing, and compliance with NJ DDD service authorization.

I understand and agree to the following:

• A participant may be absent for up to seven (7) consecutive calendar days without additional documentation.
• Any absence exceeding seven (7) consecutive calendar days requires advance notice and must be supported by appropriate medical documentation and/or prior written notice for a planned vacation or approved leave.
• Absences beyond seven (7) calendar days without required notice or documentation will be considered unapproved extended absences and may impact continued enrollment or placement upon return.

• The latest allowable drop-off time is 9:30 a.m.
• Participants arriving after 9:30 a.m. will not be accepted into the program unless prior approval has been granted by the Director or Executive Director with advance notice.

• Day Habilitation services are structured to provide a full six (6) hours of programming per scheduled day.
• Half-day services are not offered.
• All early departures must be communicated to Program Administration in advance.
• Routine, frequent, or unapproved early departures may impact service delivery, attendance expectations, and continued enrollment.

• Continued enrollment following extended absences or repeated early exits is dependent upon DDD service authorization, program capacity, and staffing availability.
• Updated medical documentation or support plans may be required prior to a participant's return to services following an extended absence.

I understand that failure to comply with this policy may result in a review of the participant's continued enrollment and services.

By signing below, I acknowledge that I understand and agree to comply with the Attendance, Absence, Arrival, and Early Exit Policy.

This form explains potential uses of client photographs/images by Hearten and allows you to grant or deny permission to Hearten to release your image for display or publication. As a safeguard, Hearten will not publish client names or any other personal identifiers unless given permission by a client or guardian.

Form #2

Please check the applicable box, read, sign and return this form to your adult day service program as soon as possible.

• If numbers two or three above are checked and no one is home when the vehicle arrives, the vehicle will continue on its usual route and bring the individual back to the day service site or an authorized location. The home representative is then responsible to transport the individual back home on this day.
• Day service participants are responsible for being ready to board the vehicle when it arrives at their home in the morning. The waiting period for picking up an individual is three (3) minutes. If there is no response from within the home during that time, the vehicle shall continue on its route and will not return that day. It is then the responsibility of the home representative to transport the individual to the program site.
• If there are repeated problems with pick up or drop off of the individual, transportation may be suspended until a corrective plan of action is implemented.
• Transportation is provided on a curb to curb basis. Transportation staff are not responsible for escorting individuals to and from the home. The day service and/or transportation provider's responsibility for the individual ceases when they step off the vehicle.

I have read, understand and agree to follow the transportation standards.

Annual Review: A new form must be completed a minimum of every five years. In the interim, this form needs to be reviewed by the IDT annually. If there are no changes, complete the information below. If there are changes a new form must be completed and signed.

I acknowledge that the above documents were provided to me in a manner I can understand. I have been informed of my rights, responsibilities, and the agency's policies regarding privacy, confidentiality, and incident reporting. I understand that I may request clarification at any time and may obtain additional copies of these documents upon request.

Please initial each item:

New Jersey Department of Human Services
Division of Developmental Disabilities

Currently, the Centers for Disease Control and Prevention¹ ² (CDC) provides the following information about COVID-19:

COVID-19 is thought to spread mainly through close contact from person to person, including between people who are physically near each other (within about 6 feet). People who are infected but do not show symptoms can also spread the virus to others. Cases of reinfection with COVID-19 have been reported but are rare. We are still learning about how the virus spreads and the severity of illness it causes.

How easily a virus spreads from person to person can vary. COVID-19 appears to spread more efficiently than influenza but not as efficiently as measles, which is among the most contagious viruses known to affect people.

• People who are physically near (within 6 feet) a person with COVID-19 or have direct contact with that person are at greatest risk of infection.
• When people with COVID-19 cough, sneeze, sing, talk, or breathe they produce respiratory droplets. These droplets can range in size from larger droplets (some of which are visible) to smaller droplets. Small droplets can also form particles when they dry very quickly in the airstream.
• Infections occur mainly through exposure to respiratory droplets when a person is in close contact with someone who has COVID-19.
• Respiratory droplets cause infection when they are inhaled or deposited on mucous membranes, such as those that line the inside of the nose and mouth.
• As respiratory droplets travel further from the person with COVID-19, the concentration of droplets decreases. Larger droplets fall out of the air due to gravity. Smaller droplets and particles spread apart in the air.
• With passing time, the amount of infectious virus in respiratory droplets also decreases.

• Some infections can be spread by exposure to virus in small droplets and particles that can linger in the air for minutes to hours. These viruses may be able to infect people who are further than 6 feet away from the person who is infected or after that person has left the space.
• This kind of spread is referred to as airborne transmission and is an important way that infections like tuberculosis, measles, and chicken pox are spread.
• There is evidence that under certain conditions, people with COVID-19 seem to have infected others who were more than 6 feet away. These transmissions occurred within enclosed spaces that had inadequate ventilation. Sometimes the infected person was breathing heavily, for example while singing or exercising.
  • Under these circumstances, scientists believe that the amount of infectious smaller droplet and particles produced by the people with COVID-19 became concentrated enough to spread the virus to other people. The people who were infected were in the same space during the same time or shortly after the person with COVID-19 had left.

¹ www.cdc.gov/coronavirus/2019-ncov/faq.html
² https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html

NJ Division of Developmental Disabilities | Receipt of COVID-19 Information Form | March 2021 | Page 1 of 4

• Available data indicates that it is much more common for the virus that causes COVID-19 to spread through close contact with a person who has COVID-19 than through airborne transmission³.

• Respiratory droplets can also land on surfaces and objects. It is possible that a person could get COVID-19 by touching a surface or object that has the virus on it and then touching their own mouth, nose, or eyes
• Spread from touching surfaces is not thought to be a common way that COVID-19 spreads

Currently authorized vaccines in the United States are highly effective at protecting vaccinated people against symptomatic and severe COVID-19. Additionally, a growing body of evidence suggests that fully vaccinated people are less likely to have asymptomatic infection and potentially less likely to transmit COVID-19 to others.

At this time, people are considered fully vaccinated for COVID-19 ≥2 weeks after they have received the second dose in a 2-dose series (Pfizer-BioNTech or Moderna), or ≥2 weeks after they have received a single-dose vaccine (Johnson and Johnson [J&J]/Janssen).

How long vaccine protection lasts and how much vaccines protect against emerging COVID-19 variants are still under investigation. Until more is known and vaccination coverage increases, some prevention measures will continue to be necessary for all people, regardless of vaccination status.

In public spaces, fully vaccinated people should continue to follow guidance to protect themselves and others, including wearing a well-fitted mask, physical distancing (at least 6 feet), avoiding crowds, avoiding poorly ventilated spaces, covering coughs and sneezes, washing hands often, and following any applicable workplace guidance. Fully vaccinated people should still watch for symptoms of COVID-19, especially following an exposure to someone with suspected or confirmed COVID-19. If symptoms develop, all people - regardless of vaccination status - should isolate and be clinically evaluated for COVID-19, including COVID-19 testing, if indicated. Fully vaccinated people should also continue to follow current CDC and NJDOH travel guidance.

Everyone, regardless of disability, is at risk for being exposed to COVID-19 and getting sick. Certain populations, including those who are older or have underlying medical conditions are more likely to become severely ill, which means that they may require hospitalization, intensive care, a ventilator to help them breathe, or may even die.

Per the CDC⁵, certain disability groups might be at an increased risk of becoming infected.

• People who have limited mobility or cannot avoid close contact with others who may be infected;
• People who have trouble understanding information or practicing measures like hand washing and social distancing;
• People who may not be able to communicate symptoms of illness.

Individuals, families, guardians, providers and other stakeholders are encouraged to review the CDC links in this document for more information.

³ Pathogens that are spread easily through airborne transmission require the use of special engineering controls to prevent infections. Control practices, including recommendations for patient placement and personal protective equipment for health care personnel in healthcare settings, can be found in Section 2 of Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the COVID-19 Pandemic.
⁴ https://www.cdc.gov/coronavirus/2019-ncov/vaccines/fully-vaccinated-guidance.html
⁵ https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-disabilities.html

NJ Division of Developmental Disabilities | Receipt of COVID-19 Information Form | March 2021 | Page 2 of 4

People with the below medical conditions are at an increased risk for severe illness at any age:

• Cancer;
• Chronic kidney disease;
• COPD (chronic obstructive pulmonary disease);
• Down Syndrome;
• Serious heart conditions, such as heart failure, coronary artery disease, or cardiomyopathies;
• Immunocompromised state (weakened immune system) from solid organ transplant;
• Severe Obesity (BMI ≥ 40 kg/m²)
• Pregnancy;
• Sickle cell disease;
• Smoking;
• Type 2 diabetes mellitus.

Based on the information available at this time, people with the following conditions might be at an increased risk for severe illness from COVID-19:

• Asthma (moderate to severe);
• Cerebrovascular disease;
• Cystic fibrosis;
• Hypertension or high blood pressure;
• Liver disease;
• Neurologic conditions, such as dementia;
• Overweight (BMI > 25 kg/m², but < 30 kg/m²);
• Pulmonary fibrosis (damaged/scarred lung tissues);
• Thalassemia (a type of blood disorder);
• Type 1 diabetes mellitus.

Immunocompromised state (weakened immune system) from blood or bone marrow transplant, immune deficiencies, HIV, use of corticosteroids, or use of other immune weakening medicines.
Per the CDC, certain disability groups might be at an increased risk of becoming infected.

• People who have limited mobility or cannot avoid close contact with others who may be infected;
• People who have trouble understanding information or practicing measures like hand washing & social distancing;
• People who may not be able to communicate symptoms of illness.

How to reduce the risk of getting COVID-19
It is especially important for people at increased risk of severe illness from COVID-19, and those who live with them, to protect themselves from getting the virus. The best way for someone to protect himself or herself and help reduce the spread of COVID-19 is to: wear a mask; stay six feet away from others; avoid crowds; avoid poorly ventilated spaces; wash your hands often; cover coughs and sneezes; clean and disinfect; and monitor your health daily.
Face coverings are a critical preventive measure and should be worn in public settings and when around people who don't live in the same household. Information on types of masks and guidance on how to best wear these masks are available from the CDC. They are most essential when social distancing is difficult. If an individual does not tolerate a face covering or it is not medically advisable to wear one, measures to reduce the risk of COVID-19 spread must occur, including social distancing, frequent hand washing, and cleaning and disinfecting frequently touched surfaces?.
Your provider can relay what precautions they are taking to lower the risk of transmission. Division policies related to COVID-19 can be found on the DHS COVID-19 Information webpage. If a self-directed model is being used, families are encouraged to consider risks and talk with their staff about screening and prevention strategies that may be used.

https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/diy-cloth-face-coverings.html
https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/cloth-face-cover-guidance.html
NJ Division of Developmental Disabilities | Receipt of COVID-19 Information Form | March 2021 | Page 3 of 4

If you or someone you know has questions about COVID-19 risk, it is recommended that you consult your health care provider, visit New Jersey's COVID-19 Information Hub, or call New Jersey's 24/7 COVID-19 Call Center at 1-800-962-1253. By signing this document, the individual or their legal representative acknowledges receipt of this information and will consider it in their planning.

NJ Division of Developmental Disabilities | Receipt of COVID-19 Information Form | March 2021 | Page 4 of 4