Fill and Sign the Wisconsin Annual Report Form

STATE OF WISCONSIN, CIRCUIT COURT,       COUNTY For Official Use IN THE MATTER OF       Name of Ward       Date of Birth Amended Annual Report on the Condition of the Ward Case No.       1. LOCATION AND ADDRESS OF WARD: The residence of the ward is in       County, State of       , and the ward’s post-office address is:       . Facility Name:       What type of residence is this? Private Home or Apartment Adult Family Home Group Home Foster Home Community-Based Residential Facility Center for Developmentally Disabled Intermediate Facility 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? Daily At least 4 times a year. Never Other:       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 nursing facility, is this the most integrated setting consistent with the ward’s needs? Yes No 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 This form shall not be modified. It may be supplemented with additional material. GN-3480, 10/06 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.