How to work with the NY State DOH 4397 Part A form, “Assisted Living Residence Resident Personal Data Form”

The “Assisted Living Residence Resident Personal Data Form” is an important form for any NY community that has the enhanced assisted living license, and ALIS fully supports this form!

Most of the fields pre-populate with data from ALIS, so you don’t have to keep filling in the same information over and over.

One area that needs some explanation is the “Significant Other” contacts in section 2 (“Personal Background”) on page 2. We have set up the DOH 4397 form so that after you click on the “Fill Significant Other Fields” button, the significant other fields populate as follows:

• If the resident this form is being filled for has a wife contact, the wife will show up as the first signification other contact.
• If the resident doesn’t have a wife contact, but does have a husband contact, then the husband contact will show up as the first signification other contact.
• If the resident doesn’t have a wife or husband contact, but does have a significant other contact, then the significant other contact will show up as the first signification other contact.
• If the resident doesn’t have any of these contacts, the significant other fields will contain “N/A”.

Please note that the “Fill Significant Other Fields” button will never show up when you print this form.

Also, the significant other fields in the form are read only, so if you want to make any changes to the contact details (for example, update a wife’s phone numbers) you need to do that in ALIS rather than in the form.

If you have any questions about this form, or any others in ALIS, please let us know.