Nutrition, Transportation, and Support Services - Forms and Information

Contact the NTS Coordinator at 465-4876 or FAX 465-1170, or by email for information, questions, or if having problems downloading any forms or documents. Email: joan.gone@alaska.gov.

Forms

• Planning
  • Planned Services & Expenditures (PSE) (Excel) (PDF)
  • Logic Model (Word)(PDF)
  • LM Evaluation Plan & Indicators (Word)(PDF)
• Annual Consumer Screening Forms
  • Consumer Characteristics (Excel) (PDF)
  • Determine Your Nutritional Needs(PDF)
• Meals
  • Cycle Menu Forms (Word) (PDF)
  • NSIP Claim For Reimbursement (Excel) (PDF)
  • DASH Eating Plan (Word)(PDF)
• Reports
  • Quarterly Cumulative Fiscal Report (DFR2) (Excel) (PDF)
  • 13 NTS Biannual Report Instructions & Examples (Word)(PDF)
  • 13 NTS Biannual Progress Report & Logic Model Evaluation FORM (Word)(PDF)

Information

• Provider Administration
  • Minimum Qualifications for Service Providers (Word) (PDF)
  • Critical Incident Reporting (PDF)
  • Reports of Harm(htm)
  • NTS Contact and SAMS User (Word) (PDF)
• Provider Operations
  • Voluntary Contributions (Word) (PDF)
  • Intent of Operations (Word)(PDF)
  • Self Evaluation
    • Annual Internal Program Evaluation (sample) (Excel)(PDF)
    • Senior Center Evaluation Survey: Outcomes (sample) (Word)(PDF)
    • Survey Cover Letter (Sample) (Word) (PDF)

Joan Gone, RD, Health Program Manager II
Senior and Disabilities Services (DSDS)
PO Box 110680, Juneau, Alaska 99811-0680
Phone: (907) 465-4876 Fax: (907) 465-1170