Quarterly Report - RCEB
Quarterly Report
Name: _______________________________ D.O.B. ________________
U.C.I. Number: ________________________ Date of Report: _________
Address: _____________________________ Period Covered:_________
_____________________________
_____________________________
Medical/Dental Update:
Medical Appointments
|Doctor’s Name |Date of Visit | Reason for Visit |Outcome |
| | | | |
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Illness and dates
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
Current Medications
|Name | Dosage | Reason |
| | | |
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| | | |
Changes in medication since last report
|Name | New or | Date | Reason |
| |discontinued? | | |
| | | | |
| | | | |
| | | | |
| | | | |
Current Weight: __________ Change since last report ? Y/N ________
Possible reasons for weight change: ______________________________________
Bank Account Balance _________________ Income ______________________
Overnight Visits: (dates, where and with whom) ___________________________________________________________________
___________________________________________________________________
Special Incident Reports: (date and event) ___________________________________________________________________
Community and Leisure Activities
|Where | Date | With Whom |
| | | |
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ISP OBJECTIVES
General Summary: If the objective does not require data collection, summarize the
status of this objective for the last six months (e.g. Consumer will reside at Westside
Home. Consumer has seemed to enjoy his roommate and home, no problems to date
with the placement…)
Data Summary: If the objective refers to skill acquisition, report what progress the
consumer has made over the last six months. If the objective refers to something
occurring or not occurring a number of times (e.g. reduce behavior from 5 times to 3
times…) report in numbers of times for the last six months.
Objective #1: ___________________________________________________________________
___________________________________________________________________
If no progress state recommendations: ____________________________________
___________________________________________________________________
___________________________________________________________________
Objective #2: ___________________________________________________________________
___________________________________________________________________
If no progress state recommendations: ____________________________________
___________________________________________________________________
___________________________________________________________________
Objective #3: ___________________________________________________________________
___________________________________________________________________
If no progress state recommendations: ____________________________________
___________________________________________________________________
___________________________________________________________________
Objective #4: ___________________________________________________________________
___________________________________________________________________
If no progress state recommendations: ____________________________________
___________________________________________________________________
___________________________________________________________________
Objective #5: ___________________________________________________________________
___________________________________________________________________
If no progress state recommendations: ____________________________________
___________________________________________________________________
___________________________________________________________________
Objective #6: ___________________________________________________________________
___________________________________________________________________
If no progress state recommendations: ____________________________________
___________________________________________________________________
___________________________________________________________________
Objective #7: ___________________________________________________________________
___________________________________________________________________
If no progress state recommendations: ____________________________________
___________________________________________________________________
___________________________________________________________________
Additional Information and Comments:
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
___________________________________________________________________
_______________________________ Date Completed __________________
(Administrator’s Signature)
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