DSHS Form 16-172 "Your Rights and Responsibilities When You Receive Services Offered by Aging and Long-Term Support Administration and Developmental Disabilities Administration" - Washington (Samoan)

This is a legal form that was released by the Washington State Department of Social and Health Services - a government authority operating within Washington.

The document is provided in Samoan. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2018;
  • The latest edition provided by the Washington State Department of Social and Health Services;
  • Easy to use and ready to print;
  • Available in French;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a printable version of DSHS Form 16-172 by clicking the link below or browse more documents and templates provided by the Washington State Department of Social and Health Services.

ADVERTISEMENT
ADVERTISEMENT

Download DSHS Form 16-172 "Your Rights and Responsibilities When You Receive Services Offered by Aging and Long-Term Support Administration and Developmental Disabilities Administration" - Washington (Samoan)

Download PDF

Fill PDF online

Rate (4.5 / 5) 74 votes
Ou Aiā ma Tiute Tatau pe a e Maua Tautua
IGOA O LE KALANI
Ofoina atu e le Aging and Long-Term Support Administration
ma le Developmental Disabilities Administration
NUMERA ID A LE ACES
Your Rights and Responsibilities When You Receive Services Offered by
Aging and Long-Term Support Administration and Developmental
Disabilities Administration
• Faailoa atu faai'uga i se tusi a le ofisa ma sau kopi
Auaunaga e Mafai Ona Maua
o lau fuafuaga o tausiga poo le vaaiga ile fuafuaga.
E iai lou aia tatau e filifili ai mai auaunaga e te agavaa e
• Talanoa i se pule pe afai ua lua feeseesea'i i se
tali. E le faamalosia ia tautua. E ono le mafai e tautua e
totogi e le Aging and Long-Term Support Administration
mataupu ma lau galue mataupu;
(ALTSA) ma le Developmental Disabilities Administration
• Talosaga mo se iloiloga faapule'aga tusa lava po ua
(DDA) ona fesoasoani atu i o'u mana'oga uma.
uma ona fai sau tagi le malie;
E ofo atu e le ALTSA ma le DDA auaunaga i le:
• Fai se tagi le malie e aunoa ma le fefe ne'i afaina
• Se fale Adult Family Home, Assisted Living Facility,
tusa po ua e talosaga mo se iloiloga faapuleaga;
Enhanced Services Facility, Nursing Facility,
• Valaau le 1-888-201-1014 ma talanoa i se lagolago;
Companion Home, Children’s Foster Home,
• Teena ai uma auaunaga;
Children’s Licensed Staffed Residential Home; DDA
• Faia ai auaunaga faaliliuupu e le totogia mo oe pe
Group Homes, Group Training Homes, ICF/IDs; POO
afai e te le tautala pe malamalama lelei i le Igilisi;
• Se fale o le tagata lava ia. Taga'i: e le faia e le
• Filifili ai, faate'a pe sui se tausi soifua agavaa; ma
ALTSA ma le DDA tausiga totino i le 24 itula/aso i le
fale o le tagata. Afai e mana'omia tausiga totino i le
• Maua ai faai'uga o sa'iliga o talaaga o soo se tasi e
24 itula, e iai isi tautua e filifili mai ai e te fiafia i ai.
te filifilia e faia le tausiga.
O lau Pule Mataupu AAA, DDA Case Resource Manager,
Ou Tiute Tatau
poo le HCS Social Service Specialist e ta'ua o le galue
E iai lou tiute tatau e:
mataupu i le pepa lenei.
• Fai ai e le galue mataupu lau iloiloga faatatau e tasi
Ou Aiā Tatau
pe sili a'e i le tausaga i se nofoaga e faigofie mo oe;
E iai lou aia tatau e:
• Faataga ai le galue mataupu e vaai i le si'omaga o
• Faafeagai ai isi ma oe i le tulaga mamalu, faaaloalo
lou nofoaga ia tasi se aso pe sili a'e i le tausaga;
ma le le faailoga tagata;
• Aumai ai ia matou ia lava ni faamatalaga e
• Teu faama'oti ese ai faamatalaga tau ia te oe ma ia i
faamae'a ai lau iloiloga faatatau;
totonu o tapulaa o tulafono ma aiaiga a le DSHS;
• Ta'u ai i lau galue mataupu pe afai ua faia e se isi
• Lē faileagaina ai, lē faatalalē atu i ai, faatauma'oiina
se faai'uga tau foma'i poo mea tau tupe mo oe;
ona o tupe, poo le tuulafoa'iina; afai o faileaga,
• Auai i le fauina o lau fuafuaga o tausiga poo le
faatalale atu, poo faatauma'oiina i tupe oe poo se isi
fuafuaga o le lagolago, ma e sainia;
tagata e te iloa, valaau lē totogia le DSHS i le 1-866-
• Malamalama ai e le mafai ona totogi lau fai tausiga
363-4276, talanoa i se isi e fesoasoani atu ia te oe;
mo auaunaga poo itula e le'i faatagaina;
• Faia ai ma le faaaloalo i au mea totino;
• Filifili ai lau lava tausiga tau foma'i;
• Ta'u atu ai auaunaga uma e mafai ona e maua ma
• Filifili ai se tausi soifua agavaa;
fai filifiliga i auaunaga e te mana'o pe le mana'o ai;
• Faia se nofoaga saogalemu e galue ai;
• Galulue faatasi ma lau galue mataupu i le fuafuaina
• Teu lilo ai talaaga na sa'ilia o tausi soifua;
o lau tausiga;
• Pe afai e te filifilia se Tausi Soifua Fai To'atasi (IP):
• Teena ni auaunaga faaopoopo e te le mana'omia i le
pulea o lau mataupu (peita'i, e tatau ona e faataga le
Malamalama o oe o lona pule galuega ma e
galue mataupu ia faatasi i le tausaga ona faia mea ia
tatau ona iai se konekarate a lau IP ae le'i
e maua ai auaunaga: faamae'a se iloiloga faatatau;
amataina ona totogi e faigaluega mo oe; ma
asiasi lou aiga ma vaai i le faiga o auaunaga mo oe);
Faamaonia i le pepa o taimi itula na galue ai
• Lē faamalosia ai oe e tali ni fesili pe faia se mea e te
lau tagata faigaluega IP mo oe;
le mana'o ai;
YOUR RIGHTS AND RESPONSIBILITIES WHEN YOU RECEIVE SERVICES
OFFERED BY ALTSA AND DDA
DSHS 16-172 SA (REV. 05/2018) Samoan
Ou Aiā ma Tiute Tatau pe a e Maua Tautua
IGOA O LE KALANI
Ofoina atu e le Aging and Long-Term Support Administration
ma le Developmental Disabilities Administration
NUMERA ID A LE ACES
Your Rights and Responsibilities When You Receive Services Offered by
Aging and Long-Term Support Administration and Developmental
Disabilities Administration
• Faailoa atu faai'uga i se tusi a le ofisa ma sau kopi
Auaunaga e Mafai Ona Maua
o lau fuafuaga o tausiga poo le vaaiga ile fuafuaga.
E iai lou aia tatau e filifili ai mai auaunaga e te agavaa e
• Talanoa i se pule pe afai ua lua feeseesea'i i se
tali. E le faamalosia ia tautua. E ono le mafai e tautua e
totogi e le Aging and Long-Term Support Administration
mataupu ma lau galue mataupu;
(ALTSA) ma le Developmental Disabilities Administration
• Talosaga mo se iloiloga faapule'aga tusa lava po ua
(DDA) ona fesoasoani atu i o'u mana'oga uma.
uma ona fai sau tagi le malie;
E ofo atu e le ALTSA ma le DDA auaunaga i le:
• Fai se tagi le malie e aunoa ma le fefe ne'i afaina
• Se fale Adult Family Home, Assisted Living Facility,
tusa po ua e talosaga mo se iloiloga faapuleaga;
Enhanced Services Facility, Nursing Facility,
• Valaau le 1-888-201-1014 ma talanoa i se lagolago;
Companion Home, Children’s Foster Home,
• Teena ai uma auaunaga;
Children’s Licensed Staffed Residential Home; DDA
• Faia ai auaunaga faaliliuupu e le totogia mo oe pe
Group Homes, Group Training Homes, ICF/IDs; POO
afai e te le tautala pe malamalama lelei i le Igilisi;
• Se fale o le tagata lava ia. Taga'i: e le faia e le
• Filifili ai, faate'a pe sui se tausi soifua agavaa; ma
ALTSA ma le DDA tausiga totino i le 24 itula/aso i le
fale o le tagata. Afai e mana'omia tausiga totino i le
• Maua ai faai'uga o sa'iliga o talaaga o soo se tasi e
24 itula, e iai isi tautua e filifili mai ai e te fiafia i ai.
te filifilia e faia le tausiga.
O lau Pule Mataupu AAA, DDA Case Resource Manager,
Ou Tiute Tatau
poo le HCS Social Service Specialist e ta'ua o le galue
E iai lou tiute tatau e:
mataupu i le pepa lenei.
• Fai ai e le galue mataupu lau iloiloga faatatau e tasi
Ou Aiā Tatau
pe sili a'e i le tausaga i se nofoaga e faigofie mo oe;
E iai lou aia tatau e:
• Faataga ai le galue mataupu e vaai i le si'omaga o
• Faafeagai ai isi ma oe i le tulaga mamalu, faaaloalo
lou nofoaga ia tasi se aso pe sili a'e i le tausaga;
ma le le faailoga tagata;
• Aumai ai ia matou ia lava ni faamatalaga e
• Teu faama'oti ese ai faamatalaga tau ia te oe ma ia i
faamae'a ai lau iloiloga faatatau;
totonu o tapulaa o tulafono ma aiaiga a le DSHS;
• Ta'u ai i lau galue mataupu pe afai ua faia e se isi
• Lē faileagaina ai, lē faatalalē atu i ai, faatauma'oiina
se faai'uga tau foma'i poo mea tau tupe mo oe;
ona o tupe, poo le tuulafoa'iina; afai o faileaga,
• Auai i le fauina o lau fuafuaga o tausiga poo le
faatalale atu, poo faatauma'oiina i tupe oe poo se isi
fuafuaga o le lagolago, ma e sainia;
tagata e te iloa, valaau lē totogia le DSHS i le 1-866-
• Malamalama ai e le mafai ona totogi lau fai tausiga
363-4276, talanoa i se isi e fesoasoani atu ia te oe;
mo auaunaga poo itula e le'i faatagaina;
• Faia ai ma le faaaloalo i au mea totino;
• Filifili ai lau lava tausiga tau foma'i;
• Ta'u atu ai auaunaga uma e mafai ona e maua ma
• Filifili ai se tausi soifua agavaa;
fai filifiliga i auaunaga e te mana'o pe le mana'o ai;
• Faia se nofoaga saogalemu e galue ai;
• Galulue faatasi ma lau galue mataupu i le fuafuaina
• Teu lilo ai talaaga na sa'ilia o tausi soifua;
o lau tausiga;
• Pe afai e te filifilia se Tausi Soifua Fai To'atasi (IP):
• Teena ni auaunaga faaopoopo e te le mana'omia i le
pulea o lau mataupu (peita'i, e tatau ona e faataga le
Malamalama o oe o lona pule galuega ma e
galue mataupu ia faatasi i le tausaga ona faia mea ia
tatau ona iai se konekarate a lau IP ae le'i
e maua ai auaunaga: faamae'a se iloiloga faatatau;
amataina ona totogi e faigaluega mo oe; ma
asiasi lou aiga ma vaai i le faiga o auaunaga mo oe);
Faamaonia i le pepa o taimi itula na galue ai
• Lē faamalosia ai oe e tali ni fesili pe faia se mea e te
lau tagata faigaluega IP mo oe;
le mana'o ai;
YOUR RIGHTS AND RESPONSIBILITIES WHEN YOU RECEIVE SERVICES
OFFERED BY ALTSA AND DDA
DSHS 16-172 SA (REV. 05/2018) Samoan
Ou Aiā Tatau (faaauau)
Faatonuga Fai Mamao
• Ta'u ai i le galue mataupu pe afai ua iai ni faaletonu i
E iai lou aia tatau e fai ai ni faatonuga fai mamao. O
lau tausi soifua po ua e le maua itula o loo talosaga
faatonuga fai mamao e aofia ai se uili soifua poo se
le tausi soifua e totogi ai;
malosi'aga faaauau faatulafono mo le tausiga o lou
• Totogi ai lau tausi soifua i masina ta'itasi pe afai o e
soifua. O faatonuga fai mamao e aofa'i i ai ou moomooga
fesoasoani i le totogiina o le tausiga o oe;
e uiga i tulaga o tausiga faafoma'i ma/poo tausiga o le
• E te lē faia ai ni uiga e lamatia ai se isi; ma
mafaufau, e aofia ai le aia tatau e talia ai pe teena se
togafitiga faafoma'i, o le mafaufau, pe faatatau i se
• Ta'u i lau galue mataupu pe afai ua iai se suiga i:
ta'otoga pe afai ua le toe mafai e lou mafaufau ona fai o
 Le tulaga o lou soifua tausiga faafoma'i;
lea faai'uga. E mafai ona e toe aveesea se faatonuga fai
 Le fesoasoani e te maua mai aiga poo nisi ofisa;
mamao i soo se taimi.
 Le nofoaga e te alaala ai; poo
 Lou tulaga tau tupe.
Auaunaga Resitala Palota
Tiute Tatau o le Galue Mataupu
E faamalosia setete uma e le National Voter Registration
Act o le 1993 e faia fesoasoani mo le resitala palota e ala
O lau galue mataupu e iai le tiute tatau e:
i o latou ofisa fesoasoani lautele. E le aafia auaunaga
Faafeagai ai ma oe i le tulaga mamalu ma faaaloalo;
poo le aofa'i o penefiti e te maua i lea ofisa ona o lau
Tausi lou tulaga faama'oti ese;
talosaga e resitala poo lou teena o le resitala palota. A e
fia maua se fesoasoani e faatumu le pepa resitala palota,
Ta'u atu ia te oe mea e mafai ona faia e le LTSA ma
matou te fesoasoani atu ia te oe. O le a le faailoaina lau
le DDA, pe le mafaia ona fai mo oe;
filifiliga e te resitala pe teena le resitala, ma e faaaoga mo
Ave ai faamatalaga mai ia te oe poo isi e fai ai se
na'o mea tau resitala. Afai e te talitonu ua faalavelave se
iloiloga fuafua e iloa ai le tulaga o se fesoasoani ma
isi i lou aia tatau e resitala poo le teena o le resitala
faatulagaina o auaunaga e mafai ona e filifili mai ai.
palota, lou aia tatau e faama'oti ese ai lau filifiliga e te
 O le iloiloga fuafua e aofia ai ou malosi'aga, o
resitala poo le talosaga e te resitala palota, poo lou aia
vaivaiga, sini, ma mea e te mana'o ai.
tatau e filifili ai le vaega faaupufai poo isi filifiliga tau upu
 O le iloiloga fuafua e aofia ai fesoasoani o loo e
fai o malo, e mafai ona faaulu sau tagi le malie i le:
maua pe mafai ona e maua mai aiga poo isi
ofisa ma le ala e te mana'o e faia ai auaunaga;
Washington State Elections Office
PO Box 40229
Fesoasoani ai ia te oe e fau se fuafuaga o tausiga
poo fuafuaga o lagolago e fesoota'i ma fesoasoani i
Olympia WA 98504-0229
tausiga totino e aofia ai au sini faapitoa, mea e te
1-800-448-4881
mana'o ai, ma au filifiliga;
Lau Saini
Ave ai faamatalaga mai ia te oe poo isi e teuteu ai
lau fuafuaga o tausiga poo fuafuaga o lagolago i
tausaga ta'itasi poo taimi ua iai ni suiga.
Saini i le laina i lalo ifo pe afai ua e malamalama i ou aia
ma tiute tatau ma tiute tatau o lau galue mataupu.
Avatu ai ia te oe se taimi ia lava e sauni ai
faamatalaga o loo mana'omia;
Faafeiloa'i ai ni faafitauli e tula'i mai i lau fuafuaga o
SAINI LE KALANI
tausiga poo lau fuafuaga o lagolago;
Faaaloalo ai i ou aia tatau ma saunia nisi ala e te oo
ai i ni fesoasoani i faaletonu o le mafaufau, neura,
ASO
vaai, faalogo, ma isi veaga o le tino; ma
Fesoasoani ia te oe e su'e se tausi soifua agavaa pe
SAINI LE SUI FAALETULAFONO
afai ua e le mauaina se tasi.
ASO
Faaaliga mo tagata faatau ma tagata faigaluega (Title VI and VII): O le Matagaluega o Tautua mo le Soifua Maloloina o le
Setete o Uosinitone e faaoo atu le avanoa tutusa mo pule o galuega ma e lē fai mea faapito i soo se vala tau galuega,
ana polokalame poo tautua e faavae i tausaga, itupa, itupa na fanau mai, ituaiga, ituaiga o ta’ua ai, tulaga tau faaipoipoga,
atunuu, lanu atunuu na fanau ai, tapuaiga poo talitonuga, sootaga faapolokiti, tulaga tau mileteri, fitafita tuai faamalolo
lelei, Vaitaimi o Vietinemi, tuueseese talu ai nei poo isi tulaga puipuia o fitafita tuai, lē manogi ni mea, tulaga o le
mafaufau, lē atoatoa le malosi, poo faaaoga se ta’ifau a’oa’oina lelei e ta’ita’ia o ia poo se meaola o tautuaina le tagata e
lē atoatoa le malosi, tutusa le totogi poo faamatalaga e fesoota’i i sela fanau.
YOUR RIGHTS AND RESPONSIBILITIES WHEN YOU RECEIVE SERVICES OFFERED BY ALTSA AND DDA
DSHS 16-172 SA (REV. 05/2018) Samoan
Your Rights and Responsibilities When You Receive Services Offered by
Aging and Long-Term Support Administration and Developmental Disabilities Administration
INSTRUCTIONS
1. Present this form to the client when completing the initial CARE assessment and reviewing the care plan or
support plan. If the client is already receiving services and did not previously sign this version of the form, present
the form to the client at the next assessment. Review the form with the client to answer any questions about the
client‘s rights and responsibilities.
2. Have the client or the client’s representative sign two copies of the form to indicate his/her understanding of the
client’s rights and responsibilities when receiving services offered by Aging and Long-Term Support
Administration and Developmental Disabilities Administration.
3. File one copy in the hard file or Document Management System (DMS) and give the other copy to the client.
YOUR RIGHTS AND RESPONSIBILITIES WHEN YOU RECEIVE SERVICES OFFERED BY ALTSA AND DDA
DSHS 16-172 SA (REV. 05/2018) Samoan
Page of 3