Effective Date
Instructions
Updated: 3/2026
Purpose
To collect initial intake information for applicants for Older Americans Act caregiver services.
Procedure
When to Prepare
Complete a Caregiver Intake form to collect demographic information, contact information, and other information needed to coordinate the right services for each person requesting caregiver services.
Items marked with an asterisk are required for federal reporting and must be completed.
Number of Copies
Complete and keep original on file.
Transmittal
Area Agencies on Aging must follow their policy and procedures for Caregiver Intake. Enter the Caregiver Intake data in the State Unit on Aging Program Uniform Reporting System (SPURS).
Detailed Instructions
Area Agency on Aging of — Enter the name of the Area Agency on Aging (AAA).
Release of Information and Client Rights and Responsibilities — Check the box after explaining the Release of Information and Client Rights and Responsibilities to the person.
Section 1 - Caregiver Identification —AAA or provider staff complete this section.
Date — Enter the date of information collection.
SPURS ID No. — Enter the caregiver’s identification number generated by SPURS, if known.
Primary Language — Enter the caregiver’s primary language.
Last Name — Enter the caregiver’s last name.
First Name — Enter the caregiver’s first name.
MI — Enter the caregiver’s middle initial.
Street Address and Apt No. — Enter the street address and, if necessary, apartment number where the caregiver resides.
City — Enter the city where the caregiver resides.
State — Enter the abbreviation of the state where the caregiver resides (i.e. enter TX for Texas).
ZIP Code — Enter the ZIP code where the caregiver resides.
County — Enter the county where the caregiver resides.
Area Code and Phone No. — Enter the caregiver’s area code and phone number and check the appropriate box to indicate if the number is for a home phone, cell phone, or other type of communication.
Date of Birth — Enter the caregiver's date of birth.
Sex — Check the box which shows the caregiver’s sex.
Email Address — Enter the caregiver’s email address.
Mailing Address — Check the box which shows if the caregiver has a different mailing address from their residential address.
Street Address and Apt No. or P.O. Box — Enter the caregiver’s mailing address. If necessary, enter an apartment number or P.O. Box.
City — Enter the city where the caregiver receives mail.
State — Enter the abbreviation of the state where the caregiver receives mail. For example, enter TX for Texas.
ZIP Code — Enter the caregiver’s mailing ZIP code.
County — Enter the county where the caregiver receives mail.
Ethnicity — Check the box which shows the caregiver’s ethnicity. Check Unknown if the person refuses to answer.
Race — Check the box which shows the caregiver’s race.
Marital Status — Check the box to show the caregiver’s marital status. Check Not Reported if the person refuses to answer.
Person Lives Alone? — Check the box which shows if the caregiver lives alone or lives with other people.
Total Number of People in Household: — Enter the total number of people living in the same household as the caregiver requesting services.
Monthly Household Income: — Enter the total household income from all sources.
At or Below Poverty? — Check the which shows if the caregiver’s income is at, below or above the federal poverty level. Use the current Department of Health and Human Services Federal Poverty Guidelines for the size of the household to determine if the caregiver is or is not in poverty.
Have you ever served in the United States Armed Forces, regardless of services or types of discharge? - Check yes, No or Chooses not to answer, as applicable.
Section 2 - Service(s) Requested — AAA or provider staff complete this section.
List of Requested Services — Enter notes about the type of help the caregiver needs.
Section 3 - Care Recipient Identification — AAA or provider staff complete this section.
Does the care recipient need an interpreter? — Select the answer to show if the person receiving care from the caregiver needs an interpreter.
Who helps in the interpretation if yes? — Enter the first and last name of the person interpreting for the care recipient.
Complete the following the care recipient is 60 or older.
Date — Enter the date of information collection.
SPURS ID No. — Enter the care recipient’s identification number generated by SPURS, if known.
Primary Language — Enter the care recipient’s primary language.
Last Name — Enter the care recipient’s last name.
First Name — Enter the care recipient’s first name.
MI — Enter the care recipient’s middle initial.
Date of Birth — Enter the care recipient's date of birth.
Sex — Check the box to show the sex of the care recipient.
Street Address and Apt No. — Enter the street address. Enter the apartment number where the care recipient lives if necessary.
City — Enter the city where the care recipient lives.
State — Enter the abbreviation of the state where the care recipient lives. For example enter TX for Texas.
ZIP Code — Enter the ZIP code where the care recipient lives.
County — Enter the county where the care recipient lives.
Area Code and Phone No. — Enter the area code and phone number of the care recipient. Indicate if the number is for a home phone, cell phone, or other type of communication.
Email Address — Enter the email address of the care recipient.
Ethnicity — Check the box which shows the ethnicity of the care recipient. Check Unknown if the person refuses to answer.
Race — Check the box which shows the race of the care recipient.
Marital Status — Check the box which shows the marital status of the care recipient. Check Not Reported if the person refuses to answer.
Section 4 - Emergency Contact Information — AAA or provider staff complete this section.
Contact Name — Enter the first and last name of the caregiver’s emergency contact.
Relationship — Enter the emergency contact person’s relationship to the caregiver.
Area Code and Phone No. — Enter the area code and phone number of the caregiver’s emergency contact.
Primary Care Physician — Enter the first and last name of the caregiver’s primary care physician.
Area Code and Phone No. — Enter the area code and phone number of the caregiver’s primary care physician.
Section 5 - Relationship to Care Recipient(s) — AAA or provider staff completes this section.
Check the box to show the caregiver’s relationship to the care recipient:
- Relationship to care recipient(s) who is 60 or older or any age if diagnosed with Alzheimer’s disease or a brain disorder —Indicate the relationship of the caregiver to the older person who gets help from the caregiver. Caregiver must be 18 or older.
- Relationship to care recipient(s) who is 18 or younger — Indicate the relationship of the older relative caregiver to the person 18 or younger who gets help from the caregiver. Does the caregiver live with the care recipient? — Check either yes or no.
- Relationship to care recipient(s) with disability who is 18 or more but not older than 59 — Indicate the relationship of the older relative caregiver to the person who gets help from the caregiver. Does the caregiver live with the care recipient? — Check either yes or no.
* Complete the following if care recipient is 18 or younger or has a disability and is 18 or more but not older than 59.
Name – Enter recipient’s name.
Date of Birth - Enter recipient’s date of birth
Sex - Enter recipient’s sex.
Relationship to Caregiver - Enter recipient’s relationship to caregiver.
*Name of AAA or Provider Staff Completing Caregiver Intake – Enter name of AAA or Provider Staff Completing Caregiver Intake.
*Date – Date Caregiver Intake was completed.