All Subsidiary Forms

A-01 Business Associate Agreement

A-02 Independent Contractor Agreement

Auto Calculating Expense Voucher (PDF fillable)

B-01 Non-Work Related Accident Report

B-02 Accident Witness Statement

B-03 Vehicle Accident Investigation Report

B-04 Employee's Report of Injury & Supervisor's Accident Form

C-01 Incident Report

C-06 (Chimes MD and International) Authorization for Automated BANK Deposit

C-06 (Chimes DE) Authorization for Automated BANK Deposit

C-06 (Chimes VA) Authorization for Automated BANK Deposit

C-06 (Chimes DC, Wednesday Pay Day) Authorization for Automated BANK Deposit

C-06 (Chimes DC, Friday Pay Day) Authorization for Automated BANK Deposit

C-06a (Chimes MD) RAPID PAYCARD Authorization

C-06a (Chimes Int’l) RAPID PAYCARD Authorization

C-06a (Chimes Delaware) RAPID PAYCARD Authorization

C-06a (Chimes VA) RAPID PAYCARD Authorization

C-06a (Chimes DC) RAPID PAYCARD Authorization

C-11 Confidential Inquiry (fillable)

C-12 Application for Employment

C-12a Applicant Review Form (fillable)

C-15 Employee Information Transmittal Form (fillable)

C-15a Leave Request Transmittal Form (fillable)

(C-15M Merit Based Contingent Wage Supplement Transmittal Form (fillable)

C-16 Application for Promotion/Transfer (fillable)

C-17 Employee Communication (fillable)

C-17a Allegation of Abuse or Neglect, Employee Communication(fillable)

C-19 Key Listing Form (fillable)

C-20a Employee Transmittal Form For Payroll (fillable)

C-25aaa Staff Observation Sheet

C-26 Employee Commendation Communication

C-43 Grant Request Form

C-46 Food Record For Three Consecutive Days

C-48 Sign-Out Sheet for Distribution of Medication

C-50 Admission Medical Information Form

C-52 Chemical/Medication Support(s) for Medical Appointments or Interventions

C-55 Documentation Procedures for the use of Chemical Support

C-56 Hospital Discharge Assessment

C-57 Release for Administering Medication

C-58 Medical Appointment Record

C-59 Consumer Menses Chart

C-60a Monthly Weight Chart

C-60b Weekly Weight Chart

C-60c Daily Weight Chart

C-62 Quality Assurance Residential Site Check

C-63 Medication Administration Information (fillable)

C-66 Chimes Transportation Agreement

C-94 Individual Program Transfer

C-99 Payroll Correction Memo

C-99a Payroll Correction Memo – Reinstatement From Suspension

C-99DC Chimes DC Payroll Correction Memo

C-152 Behavioral Principles and Strategies Refresher Training

C-153 Behavioral Principles and Strategies Attendance Roster

C-202 Facility Water Temperature Record

C-316 Rights of Persons Served

C-317 Intervention Time Recording Sheet

C-371 90-Day Review

C-403 Application (for Individuals Served)

C-410 Telephone Conversation Record (fillable WORD doc)

C-411 Conference Record

C-411 Conference Record (fillable)

C-485b Behavioral Program Review and Approval

C-485c Program Review/Summary Sheet

C-486 Behavior Management Program Annual Review Summary

C-500 Authorization to Open Mail

C-580 Trip Proposal

C-601 Fire Drill Log

C-601 (IFC Only) Fire Drill Log

C-603 International, Fax Cover Sheet (fillable)

C-603 Maryland, Fax Cover Sheet (fillable)

C-603 Delaware, Fax Cover Sheet (fillable)

C-603 Virginia, Fax Cover Sheet (fillable)

C-603 DC, Fax Cover Sheet (fillable)

C-603 Holcomb, Fax Cover Sheet (fillable)

C-654 Accounts/Payable Voucher Form

C-655 Program Expense Disbursement Sheet

C-701 Employee Expense Voucher (fillable)

C-702 Training Stipend Voucher (fillable)

C-705 Staff Training Sign-In Sheet (fillable)

C-706b Medication Technician Training Program Registration Form (fillable)

C-708MD Training Completion Report (fillable)

C-708A MD Individualized Training Verification (fillable)

C-708 (not for MD use) Training Completion Report (fillable)

C-711a Foundation, Tuition Reimbursement Announcement

C-711b Foundation, Reimbursement Agreement

C-711c Foundation, Request for Chimes Foundation Reimbursement (fillable)

C-713 Refusal of Post Exposure Medical Follow-up

C-714 Information on Hepatitis B

C-715 Hepatitis B Vaccination Declination Form

C-716 Hepatitis B Vaccination Acceptance Form

C-720 Informed Consent Upon Emp, HIV Testing in Event of Exposure

C-720a Consumer’s Admission Consent to HIV Testing in Event Exposure

C-720b Informed Consent to HIV Testing In the Event of an Exposure

C-721 HIV Test Result Form - Consumer

C-725 Volunteer/Field Student Sign-in Sheet

C-726 Volunteer/Field Student Time Log

C-740 Assessment – Bathing/Water Temperature Regulation

C-750 Volunteer Application

C-751 Volunteer Evaluation

C-752 Volunteer Student Exit Interview Form

C-753 Volunteer Referral

C-754 Request for Volunteer Service

C-755 Volunteer Program Evaluation (By Staff)

C-756 Field Student Application Form

C-757 Volunteer Program Evaluation (By Volunteer)

C-758 Parental Consent Form

C-762 Volunteer Request for Training

C-764 Volunteer Services Monthly Report

C-780 Business Card Order (fillable)

C-801 Vehicle Log

C-801a Driver Sign Out Sheet

C-804 Vehicle Roadside Assistance Procedure

C-900a Release Form-Photographs/Publications

C-902 Contracted Service Voucher

C-903 Statutory Employee Service Voucher

C-904 Maryland Independent Contractor Agreement

C-904 Virginia Independent Contractor Agreement

C-905 Release of Information Form

C-950 Gumball (fillable)

C-1013 Personal Health Info

C-1015a. Confidentiality of Medical and Program Information

C-1017 Donation of Leave

R-17 Supportive Service Agreement for the Residential Services Program

R-17 ES Supportive Service Agreement for the Eastern Shore Residential Services Program

R-17 IFC Supportive Service Agreement for the IFC Program

R-26 Resident’s Request for Withdrawal of Funds

R-26 IFS/IFC Request for Withdrawal of Funds

R-26B Request for Withdrawal of Funds, Potomac and Virginia

R-30 Representative Payee Responsibility

S-100 School Transcript

S-200 Teachers Pay for School Closings

SL-stup1 Lesson Plan

***THE FOLLOWING ARE UN-NUMBERED FORMS IN ALPHA ORDER***

DHMH-1 Internally Investigated Incident Report – Appendix 6

DHMH-2 Incident Report Form – Appendix 4

DHMH-3 Quarterly Incident Report – Appendix 5

Lift1 – Lift Operator Skills Evaluation Form

Lift 2 – Forklift Training Log

Lift 3 – Forklift Pre-Use Inspection Form

PENPAL-1 Pen Pal Biography

PENPAL-2 Application for Pen Pal Program