FACILITY NAME:  _______________________________

TODAY’S DATE:  ________________________________

FAMILY MASTER/ON-SITE LIST
LIST ALL HOUSEHOLD MEMBERS
RM. #	NAME  (LAST,   FIRST)	FAM
COMP	SEX	AGE	D.O.B.	CASE NUMBER	ADMIN. DATE	COUNSELOR	

									

									

									

									

									

									

									

									

									

									

									

									

									

									

									

ETHNIC/RACE CODES:        1.0  -  BLACK         2.0  -   HISPANIC  	 3.0   -  WHITE      	 9.0 - OTHER