SIL Physical Setting Walk Through Check List
Name of SIL Contract Provider: FORMTEXT ?????Service Area: FORMTEXT ?????Definition Compliance : Apartment SettingAn apartment setting is a room or suite of rooms with kitchen facilities designed as a residence and generally located in a building occupied by more than one household. This setting may include on-sight management.Physical Address of SIL Setting: FORMTEXT ?????Date of Walk Through: FORMTEXT ????? FORMCHECKBOX Before Contractor signature FORMCHECKBOX After Contractor signatureIn an apartment complex? FORMCHECKBOX Yes FORMCHECKBOX No Name of apartment complex: FORMTEXT ?????Number of apartments in complex: FORMTEXT ?????Number of occupants in apartment: FORMTEXT ????? Number of bedrooms: FORMTEXT ?????Number of occupants per bedroom: FORMTEXT ?????#ItemMetTechnicalAssistance Yes NoComments(A No under Met or a Yes under Technical Assistance must have an explanation under Comments)1Room or suite of rooms with kitchen facilities designed as a residence FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????2Located in a building occupied by more than one household. FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????3On-sight apt. management FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????4On-sight SIL management FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????Meets DFPS definition for SIL type setting of: Apartment Setting: FORMCHECKBOX Yes FORMCHECKBOX No Comment (Must comment if “No” is selected): FORMTEXT ?????Name of SIL Contract Provider: FORMTEXT ?????Service Area: FORMTEXT ?????Name of Young Adult for whom walk through is conducted (if applicable): FORMTEXT ?????B. Suitability: for Apartment Setting identified in Section A: #ItemMetTechnicalAssistance Yes NoComments(A No or N/A under Met or a Yes under Technical Assistance must have an explanation under Comments)1Exterior House Condition Acceptable:-Outside grounds-Outside lighting-House Exterior FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????2Interior Condition Acceptable.-General Cleanliness-Floors-Walls-Windows FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????3Is Setting approved for use by a Young Adult who is in need of ADA accommodations. FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????4Fire Safety. -Up to Date Fire Extinguisher-Working Smoke Alarm(s) in: Bedrooms Hallways Living/Dining Room Other FORMTEXT ?????-Easy Access to Exits-Combustibles Items Stored Properly-Electrical FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????5Furnishings Condition Acceptable. -Bed frame-Mattress-Dresser-Closet-Table-Chair-Sofa-Individual storage area for non-food items FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????6Working Appliances. -Stove-Refrigerator-Microwave (optional) FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????7Working Utilities for Home.-Water-Running Hot Water-Running Cold Water-Electric-Gas-Sewage-Septic FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????8Working Bathroom. -Working toilets-Showers-Bathtub-Running Hot Water-Running Cold Water FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????9Household cleaning supplies FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????10Storage space for dry food FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????11On-site Laundry. -Washing machine-Clothes dryerIf no on-site laundry, Proximity of off-site Laundry -Within 1 mile-within 2 miles-within 5 miles-over 5 miles FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????12Laundry Supplies FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????13Bus Stop Available. If available – distance: -within 1 mile-within 2 miles-within 5 miles- over 5 miles FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????14Grocery Store Available. If available – distance: -within 1 mile-within 2 miles-within 5 miles-over 5 miles FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????15Access to library or other educational resources. If available – distance: -within 1 mile-within 2 miles-within 5 miles-over 5 miles FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????16Posted rules for occupants/ others FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????17Key provided to Young Adult for:-external building complex-young adult’s section of apartment if closed off from others-bedroom FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????Participant(s) Information:Signature:Date:Printed Name: FORMTEXT ?????Position: FORMTEXT ?????Phone: FORMTEXT ?????Email: FORMTEXT ?????Signature:Date:Printed Name: FORMTEXT ?????Position: FORMTEXT ?????Phone: FORMTEXT ?????Email: FORMTEXT ?????Signature:Date:Printed Name: FORMTEXT ?????Position: FORMTEXT ?????Phone: FORMTEXT ?????Email: FORMTEXT ?????Recommendation to use: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes, with follow up completed: FORMTEXT ????? ................
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