Safe and Connected Yearly Evaluation form

We would like to take this opportunity to check that we have the correct details for the Service User and the Service User's Contacts. Please can we ask you to complete the details below and submit on completion. This form should take no more than 5 minutes to complete. If you see a '*' this means the details required are mandatory.

Name Of Service User *

Alarm ID *

Home Telephone Number *

Mobile Number

Email Address

NHS Number

Existing Medical Condition(s)

Any New Medical Conditions In The Last 12 Months? *

Personal Contacts Details - First Contact's Details

First Contact's Name *

Relationship To Service User *

First Contact's Address *

Home Telephone Number *

Mobile Number *

Secondary Mobile Number

Please Tick Appropriate Box *

Next Of Kin
Key Holder
Responder

Is There A Second Contact *

Yes
No
Unsure

Professional Contacts

GP Name *

GP Telephone Number *

GP Address

Home Care Agency Name

How Many Times A Day Do Carers Attend?

What Times Do The Carers Attend?

Every year we like to take the time to assess if the equipment installed in your home is meeting your needs and to ascertain if any changes are required. For us to be able to establish this, please answer the below questions:

Annual User Re-Evaluation Questions

Is the equipment currently installed in your home helping to meet your needs and requirements? If you answer ‘No’, then please provide the reason) *

Have there been any changes to your health and/or personal circumstances in the past 12 months? If you answer ‘Yes’, then please provide what these changes are) *

Would you like us to visit you at home to carry out a re-evaluation to identify if you could benefit from any additional equipment? *

I certify that the above information is correct and authorise Safe & Connected to use this information.

Authorisation

Who is completing this form? *

Service User
Someone On Behalf Of The Service User

Full Name Of Person Completing The Form *

Date *

Day Month Year

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