Free GN-3480 - Wisconsin

For Official Use

STATE OF WISCONSIN, CIRCUIT COURT,
Amended

COUNTY

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: The residence of the ward is: (street, city, county, state) and the ward's post-office address is: (street, city, state) Facility Name: What type of residence is this?
Private Home or Apartment Community-Based Residential Facility Adult Family Home Center for Developmentally Disabled Group Home Intermediate Facility Foster Home

, .

Nursing Facility

Other: Is your ward in a locked unit?

Yes

No

2. HEALTH AND LIVING CONDITIONS OF THE WARD: A. How often do you personally observe the living conditions and care of the ward? B. Do you contact your ward in other ways? Telephone Mail Other: C. Has your ward's physical or mental condition changed in the last year? No change Improved Worsened Please explain: 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 health care and social service providers? Yes No Please explain: 3. LEAST RESTRICTIVE ENVIRONMENT CONSISTENT WITH THE NEEDS OF THE WARD: A. Is the ward living in the least restrictive environment for your ward's needs? Yes No B Has your ward been transferred to a more or less restrictive environment in the last year? No change. To a less restrictive environment. To a more restrictive environment. Please explain change and date: C. If your ward has developmental disabilities and is currently protectively placed in an intermediate facility or Yes No 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 Court Official:

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, 04/08 Annual Report on the Condition of the Ward

§54.25(1)(a), Wisconsin Statutes

This form shall not be modified. It may be supplemented with additional material.