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Click ‘Get Form’ to open the Texas Department of Aging and Disability Services Form 0066 in our platform.
Begin by entering the name of the resident in the designated field. This is crucial for identifying who the monitoring request pertains to.
Next, fill in the name of the requestor, ensuring that it is clear who is making the request for authorized electronic monitoring.
Indicate whether a video surveillance camera will be used by selecting 'Yes' or 'No'. If 'Yes', provide details on how the camera should be unobstructed or under what circumstances it may be obstructed.
Answer whether the resident resides in a multi-person room by selecting 'Yes' or 'No'. This information is important for compliance with privacy regulations.
Finally, ensure that either the resident, guardian, or legal representative signs and dates the form. Select and circle the appropriate title before submitting.

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