East Sussex Pilot SAQ; TASC Questionnaire (pdf - 512Kb)

Thank you for completing this form
Please confirm that:
You are over 18 years of age or if you are caring for a person
you are over 16 years of age.
That you or the person you are caring for lives within our local
authority East Sussex.
You are aware that the information you are providing to us may be
used or shared with relevant parties, family or organisations to enable
us to help assist your needs.
That information held will be stored electronically in a secure and
confidential Health and Social Care Records.
That if the information provided to us indicates any evidence of risk of
self harm or harm to others or in the community, we may take the
appropriate action in accordance to our duty of care as a local
authority.
You are aware that we can not guarantee that any service or
equipment selected within the assessment is available; however East
Sussex Adult Social Care will help support and assist you in finding
alternative options.
That you can confirm that you have read the eligibility criteria.
to
By ticking this box you are confirming that you understand and agree
the above terms and conditions.
Your signature
Date
Please return this form to:
Kenny Mackay, Project Manager, In-control
St Mary‟s House, St Leonard‟s Rd, Eastbourne, Sussex, BN21 3UU
East Sussex County Council
Adult Social Care Department
Page 14 of 15
Self Assessment Questionnaire
K Mackay In-Control Pilot (Health) – V2