Cuyahoga DD Housing Vacancy Form
Please complete this form to help us best understand specific information related to a residential vacancy you have. Any field with an asterisk (*) requires a response. If you have questions, please contact Ann Jones at 216-736-2658. Thank you.
What has led to a vacancy? Please describe.
*
Name of person who moved or is deceased:
*
First Name
Last Name
If the person is deceased, select the date of death.
-
Month
-
Day
Year
Date
If the person has moved, where are they moving to?
Please Select
Jail/prison
Family/friend home
Own apartment
Congregate home
ICF/IDD
Nursing facility
Other
If you selected "other," provide additional details.
If the person has moved, what is his/her new address?
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Information about the vacancy
Address of vacancy:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Anticipated date of availability:
*
-
Month
-
Day
Year
Date
Name of provider agency:
*
Provider agency contact person:
*
First Name
Last Name
Provider agency contact person phone number:
*
Provider agency contact email:
*
Vacancy is eligible for:
*
Male
Female
Coed
Shared or single bedroom?
*
Shared
Single
Is the vacancy on the 1st or 2nd floor?
*
1st floor
2nd floor
Number of staff on 1st shift:
*
Number of staff on 2nd shift:
*
Number of staff on 3rd shift:
*
Is this a North Coast Community Home?
*
Yes
No
Vacancy funding:
*
ICF/IID
IO Waiver
Licensed IO Waiver
Shared Living
Other
If this is an ICF/IID vacancy, list the hours a nurse is in the home and describe the types of nursing services provided in this home.
If this is a waiver home, enter name of Support Administrator:
First Name
Last Name
Information about the people currently living in the home
Total number of people living in the home when it is at capacity:
*
The home is:
*
Males only
Females only
Coed
Age range of people living in the home:
*
Does anyone in the home use adaptive equipment for mobility?
*
Yes
No
If someone does use adaptive equipment for mobility, please describe.
Functional level of intellectual deficits:
*
Describe behavior support needs currently supported in the home:
*
What are the behavioral support needs that can be accommodated within the home? Be sure to note if there are any behavioral support needs that would NOT be able to be supported.
*
Describe, in detail, the type of person who would do well in this home.
*
Describe, in detail, the types of activities people who live in this home participate in at the home and in the community on a regular basis.
*
Information about the home
What type of home is it?
*
Single family home
Apartment
Duplex
How many stories is this home?
*
Single (ranch)
Two/multiple levels
Is this home close to the street?
*
Yes
No
If this is an ICF/IID home, list the name of the day program.
Select each that applies to this home.
Wheelchair accessible
Accessible bathroom
Wheelchair accessible van/vehicle available
If this home is currently not accessible, can it be modified in the future?
Yes
No
Describe the home's outdoor/backyard space.
*
Describe any special features of this home.
Additional information (optional)
Please provide any additional information that can assist us in sending you appropriate referrals for this vacancy.
SUBMIT
Should be Empty: