Home Health Agency Aide for Medically Fragile Children Assessment

Pursuant to section 400.54, F.S., this form collects data on services provided from October 1st of the previous year to September 30th of the current year for licensees that provide skilled services to children under the age of 21.
AHCA Form 3110-9003, April 2024
59A-8.0099, F.A.C.
Licensee Information
* Field required
Employment

* Your agency provided home health services to children under the age of 21 during the reporting period

* Your agency employed a home health aide for medically fragile children (AMFC) during the reporting period

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Hospitalization During Reporting Period (for children attended by an AMFC)
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Hospitalizations During Reporting Period (for children not attended by an AMFC)
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Caregiver Satisfaction and Additional Support Needs (for agencies that employed an AMFC)

Using the slider below, provide the average AMFC satisfaction with the program based on your internal satisfaction survey:

Very Unsatisfied Very Satisfied
Training and Education
Transportation Needs
Community Support
Individual Needs