ICF COMMUNITY EXPERIENCE NOTIFICATION
Individual Name (person receiving services):
*
First Name
Last Name
ICF Location
*
A1
A2
A3
B1
B2
B3
C2
C3
JOHNSTOWN
How many staff will be attending the community experience?
1
2
3
4
Staff #1 completing community experience:
*
First Name
Last Name
Staff #2 completing community experience:
*
First Name
Last Name
Staff #3 completing community experience:
*
First Name
Last Name
Staff #4 completing community experience:
*
First Name
Last Name
Start date of community experience:
*
-
Month
-
Day
Year
Date
Start Time (Departure for community experience:
*
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
Minutes
AM
PM
AM/PM Option
End date of community experience:
*
-
Month
-
Day
Year
Date
End Time (Return to facility from community experience (NOTE: nursing responsible to coordinate medication arrangements if during med times)
*
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Destination--place for community experience/purpose (be specific):
*
Amount of individual funds requested for the community experience:
*
NOTE: ALL receipts must be turned in to payee within 3 days of the event. IF not, staff may receive corrective action per policy.
Amount of Open Door funds requested for the community experience for STAFF (per policy):
*
NOTE: ALL receipts must be turned in to payee within 3 days of the event. IF not, staff may receive corrective action per policy.
Form completed by:
*
First Name
Last Name
Email of Person completing form for response:
*
example@example.com
Submit
Community experience
*
Approved
Not approved
Name of person approving (payee) based on funds availability:
*
First Name
Last Name
Reason, if not approved
Should be Empty: