Personal Belongings Inventory

Facility Information

Assisted Living Facility Name:
Facility Address:
Unit #
Zip:
Facility Phone:
Inventory Completion Date: Day12345678910111213141516171819202122232425262728293031Month1 January2 February3 March4 April5 May6 June7 July8 August9 September10 October11 November12 DecemberYear1900190119021903190419051906190719081909191019111912191319141915191619171918191919201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023202420252026202720282029203020312032203320342035

1. Resident Information

• Resident Full Name:
• Date of Birth: Month1 January2 February3 March4 April5 May6 June7 July8 August9 September10 October11 November12 DecemberDay12345678910111213141516171819202122232425262728293031Year1900190119021903190419051906190719081909191019111912191319141915191619171918191919201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023202420252026202720282029203020312032203320342035
• Room/Apartment Number:
• Move-in Date: Day12345678910111213141516171819202122232425262728293031Month1 January2 February3 March4 April5 May6 June7 July8 August9 September10 October11 November12 DecemberYear1900190119021903190419051906190719081909191019111912191319141915191619171918191919201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023202420252026202720282029203020312032203320342035

2. Purpose of Personal Belongings Inventory

The purpose of this inventory is to document all personal belongings brought by the resident into the assisted living facility. This record helps:
✔ Ensure belongings are properly tracked and safeguarded.
✔ Prevent disputes or loss of items by maintaining an updated list.
✔ Assist families and caregivers in keeping an organized record of the resident’s possessions.
✔ Facilitate seamless relocation if the resident moves rooms or transfers facilities.

This document will be stored in the resident’s personal file and mus be reviewed periodically for accuracy. Any changes, additions, or removals of personal items must be recorded and acknowledged by the resident or their representative.

3. Inventory of Personal Belongings

Clothing & Accessories

List all clothing items such as shirts, pants, shoes, coats, and accessories (watches, hats, scarves, etc.).
Details to note:

Examples:

• Blue sweater – Good condition – Labeled with resident’s name
• Black sneakers – Worn condition – Labeled with resident’s name
• Blue Jeans - New Condition - Labeled with resident's name

Personal Electronics & Devices

This includes phones, tablets, hearing aids, watches, televisions, or other electronic devices.
Details to note:

Examples:

• Smartphone (Samsung Galaxy S20) – Good condition – Charger provided
• Digital hearing aid – New condition – Extra batteries included

Furniture & Room Décor

For residents who bring their own furniture, lamps, rugs, picture frames, or small appliances.
Details to note:

Examples:

• Wooden nightstand – Good condition – Placed next to bed
• Small reading lamp – New condition – On desk

Personal Care & Hygiene Products

Includes toiletries, grooming tools, and any special hygiene products.
Details to note:

Examples:

• Electric toothbrush – New condition – Kept in bathroom cabinet
• Shaving kit – Good condition – Needs refill every 3 months

Books, Important Documents & Papers

Personal books, journals, folders, and any medical/legal documents kept in the resident’s possession.
Details to note:

Examples:

• Bible – Good condition – Kept on bedside table
• Personal journal – Worn condition – Stored in top dresser drawer

Valuables & Sentimental Items

Includes jewelry, family photos, keepsakes, and other items of significant personal value.
Details to note:

Examples:

• Gold wedding ring – Good condition – Worn daily
• Framed family portrait – New condition – Hung on wall

Other Miscellaneous Items

List any additional personal belongings that do not fit the above categories.

4. Summary of Inventory

• Total Number of Items Listed:
• Total Estimated Value of Items:

5. Acknowledgment & Agreement

By signing below, I confirm that the listed belongings are accurate and complete. I understand that:
✔ The facility is not responsible for lost, stolen, or damaged items, unless otherwise stated in the facility’s policies.
✔ It is my responsibility (or my family’s) to update this inventory when new items are added or removed.
✔ Any disputes regarding missing items will be addressed based on this document.

Resident or Representative Signature:

Facility Representative Signature:

6. Updates & Modifications

All additions, removals, or modifications to the personal belongings inventory must be recorded below.

Date of Change: Day12345678910111213141516171819202122232425262728293031Month1 January2 February3 March4 April5 May6 June7 July8 August9 September10 October11 November12 DecemberYear1900190119021903190419051906190719081909191019111912191319141915191619171918191919201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023202420252026202720282029203020312032203320342035
Description of Item(s) Updated:
Updated Condition:
Resident/Representative Signature:

7. Facility Use Only

This section is to be completed by facility staff for verification purposes.

Inventory Verified By:
Date of Verification: Day12345678910111213141516171819202122232425262728293031Month1 January2 February3 March4 April5 May6 June7 July8 August9 September10 October11 November12 DecemberYear1900190119021903190419051906190719081909191019111912191319141915191619171918191919201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023202420252026202720282029203020312032203320342035
Signature:

Instructions for Facility Staff:

✔ Encourage residents and families to update this inventory every 3-6 months.
✔ If an item is lost or misplaced, record the incident and resolution process.
✔ Provide copies of this inventory to the resident and their family upon request.

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