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Annual Report On The Condition Of The Ward GN-3480 - Wisconsin
|Annual Report On The Condition Of The Ward Form. This is a Wisconsin form and can be used in Guardianship Circuit Court Statewide .||
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FORM SUMMARY Name of Form: Form Number: Statutory Reference: Benchbook Reference: Purpose of Form: Annual Report on the Condition of the Ward GN-3480 §54.25(1)(a), Wisconsin Statutes GA-1, GA-2 For guardian of the person to report on the condition and location of ward; make recommendations regarding the ward; report on whether the ward is living in the least restrictive environment consistent with the needs of the ward. Guardian of the person. Original to court. Copy to the county department designated under §55.02, Wisconsin Statutes or its designee. Who Completes It: Distribution of Form: Accompanying Forms: New Form/Modification: Modifications: Comments: About this form: PLEASE BE INFORMED: This form is based on unofficial text from Revisor of Statutes. Modification; last update 01/20/06 Modified form to comply with 2005 Wis. Acts 264, 387 and 388. This form is the product of the Wisconsin Records Management Committee, a committee of the Director of State Court's Office and a mandate of the Wisconsin Judicial Conference. If you have additional information that does not change the meaning of the form, attach it on a separate page. The form itself shall not be altered. Date: 10/05/2006 Page 1 American LegalNet, Inc. www.FormsWorkflow.com STATE OF WISCONSIN, CIRCUIT COURT, COUNTY For Official Use Amended IN THE MATTER OF Name of Ward Annual Report on the Condition of the Ward Case No. Date of Birth 1. LOCATION AND ADDRESS OF WARD: County, State of The residence of the ward is in . and the ward's post-office address is: Facility Name: What type of residence is this? Foster Home Group Home Adult Family Home Private Home or Apartment Center for Developmentally Disabled Community-Based Residential Facility Other: Nursing Facility Intermediate Facility No Yes Is your ward in a locked unit? , 2. HEALTH AND LIVING CONDITIONS OF THE WARD: A. How often do you personally observe the living conditions and care of the ward? Other: Never At least 4 times a year. Daily Other: Mail Telephone B. Do you contact your ward in other ways? C. Has your ward's physical or mental condition changed in the last year? Worsened Please explain: Improved No change D. Are you endeavoring to secure necessary care or services in the ward's best interest by regularly examining the ward's medical records, participating in staff meetings and treatment decisions, and consulting with No Please explain: Yes health care and social service providers? 3. LEAST RESTRICTIVE ENVIRONMENT CONSISTENT WITH THE NEEDS OF THE WARD: No Yes A. Is the ward living in the least restrictive environment for your ward's needs? B Has your ward been transferred to a more or less restrictive environment in the last year? To a more restrictive environment. To a less restrictive environment. No change. Please explain change and date: C. If your ward has developmental disabilities and is currently protectively placed in an intermediate facility or No Yes nursing facility, is this the most integrated setting consistent with the ward's needs? Please Explain: 4. RECOMMENDATIONS REGARDING THE WARD: See attached. File original with Register in Probate: Send copy to: (Board or Agency) Signature of Guardian(s) Date Signed Guardian's Telephone Number Guardian's Name and Address ( Check if address changed in last 12 months.) GN-3480, 10/06 Annual Report on the Condition of the Ward §54.25(1)(a), Wisconsin Statutes American LegalNet, Inc. www.FormsWorkflow.com This form shall not be modified. It may be supplemented with additional material.