This form is used for long-term care assessment and application as part of the panelling process for long-term care, and for application to transfer from one facility to another. The form can be used for personal care home placement, chronic care placement, supportive housing placement and companion care placement. This form is applicable to Manitoba Health, Seniors and Active Living, the regional health authorities, personal care home facilities, and those patients applying for long-term care assessment and their families/representatives. The form is filled out by the applicant for long-term care assessment or their representative, by the attending physician, by the nurse assessor, by the social assessor, by the case coordinator and by the assessment panel. The form is processed by Manitoba Health, Seniors and Active Living.