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How to use or fill out doh 5176 with our platform
- Click ‘Get Form’ to open the doh 5176 in the editor.
- Begin by entering the 'Facility Name' and 'Operating Certificate Number' at the top of the form. This information is essential for identifying your facility.
- Next, input the 'ACF Capacity' to indicate how many residents your facility can accommodate.
- In the 'Resident’s Name' section, list each resident's name. Ensure accuracy as this data is crucial for record-keeping.
- For 'Level of Care', check all applicable boxes (AH, EHP, ALR, EALR, SNALR, ALP) that correspond to each resident's care level.
- Fill in the 'Room #' where each resident resides. This helps in tracking their location within the facility.
- Indicate the month and year at the designated area to specify when this report is being completed.
- If a resident is absent, mark one of the codes (H, V, M, O) in the date box to clarify their status.
- Finally, complete the 'Days of Care' section by marking occupied days and calculating totals as needed.
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