Comprehensive Functional Assessment of Direct Care ...



DEVELOPMENTAL DISABILITIES ADMINISTRATION (DDA)Comprehensive Functional Assessment of Direct CareIndependent Living SkillsRESIDENT’S NAME FORMTEXT ?????RESIDENCE FORMTEXT ?????ASSESSMENT DATE FORMTEXT ?????DSHS NUMBER FORMTEXT ?????Assessor’s NameAssessor’s Job TitleShiftACM’s Initials FORMTEXT ????? FORMTEXT ????? FORMTEXT ? FORMTEXT ????? FORMTEXT ????? FORMTEXT ? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?DirectionsUse the codes below, unless otherwise specified, to complete the “Skills” section on each page. If you have questions or need clarification contact your Supervisor or HPA.PhysicalResident does 0% - 24% of task by themselves. Hand over hand and verbal assistance is provided to complete the task.GesturalResident performs task approximately 25% - 49% by themselves. Hand over hand and/or verbal assist is provided. Staff assists to initiate or carry out skill.VerbalResident performs approximately 50% - 74% of task by themselves. Physical prompt and/or verbal assist is provided. IndependentResident performs approximately 75% - 99% of task by themselves. Verbal assist, no physical assist is provided.Self-ReliantResident performs 100% of task by themselves. Does not require prompting and manages all steps in the skill.Not Applicable or N/ADoes not apply to the individuals function in daily life or the individual has not had the opportunity to use the skill in their daily environment. Designates and Area of Resident’s Rights:After initial assessment, subsequent assessors are to identify the assistance required, if the assistance required is different from the initial assessment.SocializationSkills:On each line below, enter the number that best represents the resident’s present level of ability for each skill:1. Physical3. Verbal5. Self-Reliant2. Gestural4. IndependentN/A Not Applicable FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Uses greeting to start conversation FORMCHECKBOX Y FORMCHECKBOX NListens when others speak FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Ends conversation appropriately FORMCHECKBOX Y FORMCHECKBOX NInitiates interaction with peers FORMCHECKBOX Y FORMCHECKBOX NInitiates interaction with staff FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Gets attention calmly by gesture (i.e., touches other person on arm) FORMCHECKBOX Y FORMCHECKBOX NParticipates in Advocacy Services (i.e., Peoples First, Voter Training) FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Gets attention by speaking calmly (i.e., waits for pause, says excuse me) FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Interacts with peers FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Interacts with staff FORMCHECKBOX Y FORMCHECKBOX NLikes to be near preferred peer FORMCHECKBOX Y FORMCHECKBOX NLikes to be near preferred staff FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Moves away from stressful situations / interactions FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Respects others’ personal space FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Respects others’ possessions FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Sends mail FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Uses the phoneCOMMENTS / IMPORTANT TO AND FOR / OPPOORTUNITIES TO INCREASE INDEPENDENCE AND RIGHTSBathingSkills:On each line below, enter the number that best represents the resident’s present level of ability for each skill:1. Physical3. Verbal5. Self-Reliant2. Gestural4. IndependentN/A Not Applicable FORMCHECKBOX Y FORMCHECKBOX NCommunicates need for bathing FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Cooperates with bathing tasks FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Gathers / puts away bathing items FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Safely enters / exits the tub / shower FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Turns water on / off FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Opens containers FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Pours shampoos FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Shampoos hair FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Rinses hair FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Applies soap to wash cloth FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Uses washcloth FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Washes face FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Washes front of body FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Washes back of body FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Rinses self FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Dries self FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Maintains privacy during shower / bath FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Picks up after self (towels, shampoo, dirty laundry)Bathing Safety Issues / Risks FORMCHECKBOX Y FORMCHECKBOX NHas a seizure disorder FORMCHECKBOX Y FORMCHECKBOX NDisplays hazard awareness in bathing area (wet floor, etc.) FORMCHECKBOX Y FORMCHECKBOX NUses grab barsResident Preferences FORMCHECKBOX Shower FORMCHECKBOX Tub FORMCHECKBOX Expresses preferences: FORMTEXT ?????Level of Supervision for Bathing: FORMCHECKBOX Please specify: FORMTEXT ?????COMMENTS (EXAMPLES: 1) Resident fell four times this year in the bathing area; 2) Resident’s bath recently moved to PM’s and is doing much better with their bathing routine; and 3).resident can put shampoo in hair but should work on rinsing hair):DressingSkills:On each line below, enter the number that best represents the resident’s present level of ability for each skill:1. Physical3. Verbal5. Self-Reliant2. Gestural4. IndependentN/A Not Applicable FORMCHECKBOX Y FORMCHECKBOX NTolerates dressing process FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Selects appropriate color combinations FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Selects appropriate clothing for season / activity FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Knows when clothing needs to be changed FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Grasps / holds clothing articles FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Knows when clothes are right side out vs. inside out FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Recognizes modesty issues during dressing FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Puts on bra FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Puts on shirt FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Puts on underwear FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Puts on pants FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Puts on socks FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Puts on shoes on correct feet FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Uses Velcro closures FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Ties laces FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Wears appropriate footwear in the daytime FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Wears appropriate footwear at night FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Maintains privacy during dressing FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Removes shoes FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Removes socks FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Removes pants FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Removes shirt FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Removes bra FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Removes underwear FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Fastens buttons FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Zips zipper FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Applies / removes beltResident Preferences FORMCHECKBOX Selects own clothing FORMCHECKBOX Uses adaptive / assistive device(s). If yes, specify: FORMTEXT ????? FORMCHECKBOX Expresses preferences: FORMTEXT ?????COMMENTS (EXAMPLES: 1) Resident would benefit from learning how to put shoes on correct feet; 2) Resident should not wear clothing with buttons or snaps; and 3) It is important that the resident wears baseball hats):Hygiene / GroomingSkills:On each line below, enter the number that best represents the resident’s present level of ability for each skill:1. Physical3. Verbal5. Self-Reliant2. Gestural4. IndependentN/A Not Applicable FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Knows when to brush teeth FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Opens toothpaste tube FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Puts toothpaste on toothbrush FORMCHECKBOX Y FORMCHECKBOX NTolerates toothbrush FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Makes brushing motions FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Brushes teeth / gums FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Uses dental floss FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Rinses mouth FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Turns on water FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Rinses toothbrush and puts away FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Applies soap to hands FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Makes rubbing motion with hands FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Washes face FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Rinses hands FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Dries hands FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Gathers / puts away grooming items FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Brushes / combs hair FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Styles hair FORMCHECKBOX Y FORMCHECKBOX NTolerates beautician / barber cutting hair FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Requests hair appointment FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Applies deodorant FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Aware of when to be shaved FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Shaves self with electric razor FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Mouth wash (fluoride rinse) FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Applies aftershave / cologne / perfume FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Provides own fingernail care FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Uses nail clippers FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Blows nose with tissue FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Understands need for good hygiene / grooming FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Uses mirror during care FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Applies make-up FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Cleans dentures FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Cleans glasses FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Cares for hearing aid FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Provides own Menses careResident Preferences FORMCHECKBOX Expresses preferences: FORMTEXT ?????COMMENTS (EXAMPLES: 1) Resident has expressed fear that soap will burn eyes; AND 2) Resident just received glasses. Could learn to store properly):ToiletingSkills:Check yes or no below:YESNO FORMCHECKBOX FORMCHECKBOX Continent of bladder FORMCHECKBOX FORMCHECKBOX Continent of bowel FORMCHECKBOX FORMCHECKBOX Recognizes wet / dry FORMCHECKBOX FORMCHECKBOX Episodes of daytime incontinence FORMCHECKBOX FORMCHECKBOX Episodes of nighttime incontinenceOn each line below, enter the number that best represents the resident’s present level of ability for each skill:1. Physical3. Verbal5. Self-Reliant2. Gestural4. IndependentN/A Not Applicable FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Indicates needs for bathroom FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Uses the toilet FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Asks to be changed if wet or soiled FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Changes wet clothing FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Knows location of bathroom FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Selects correct restroom from signs FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Knocks on bathroom door before entering FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Shuts bathroom / stall door / curtain FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Uses hand rails / grab bars as needed FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Pulls clothes down before eliminating FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Pulls clothes up after eliminating FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Uses toilet paper to wipe self FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Flushes toilet FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Washes hands after using bathroom FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Uses towel to dry hands FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Adjust clothing prior to leaving bathroom areaEquipment Needed: Check all adaptive equipment used: FORMCHECKBOX Adult incontinence briefs FORMCHECKBOX Commode chair FORMCHECKBOX Urinal FORMCHECKBOX Bed panResident Preferences: FORMCHECKBOX Expresses preferences: FORMTEXT ?????COMMENTS / OPPORTUNITIES FOR INCREASING INDEPENDENCE AND RIGHTS FOR SELF-CARE SKILLS (TOILETING, DRESSING, HYGIENE AND BATHING) (EXAMPLES: 1) Resident prefers familiar staff to assist; 2) Communicates need to use bathroom by agitation; AND 3) Resident should learn to use a sign for bathroom to increase success):Eating / DiningSkills:On each line below, enter the number that best represents the resident’s present level of ability for each skill:1. Physical3. Verbal5. Self-Reliant2. Gestural4. IndependentN/A Not Applicable FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Locates dining room FORMCHECKBOX Y FORMCHECKBOX NSits in preferred seating location in dining room FORMCHECKBOX Y FORMCHECKBOX NTolerates mealtime activities FORMCHECKBOX Y FORMCHECKBOX NCooperates with being fed FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Feeds self FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Eats at a reasonable pace FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Eats without spillage FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Displays appropriate table manners FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Discriminates finger food from non-finger food FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Discriminates between hot / cold food FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Discriminates appropriate utensil use FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Uses a knife to cut food FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Butters bread / spreads FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Uses fork FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Uses spoon FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Uses napkin FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Drinks from a cup / glass FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Drinks from a straw FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Drinks from a water fountain FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Opens drink / beverage container FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Pours liquid from pitcher FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Opens sealed food items FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Uses condiments FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Takes item of a tray FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Participates in cafeteria style dining / food line FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Dishes up appropriate serving FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Passes serving bowl / pitcher FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Participates in family style dining FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Understands diet / diet consistency FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Understands “healthy food” vs “junk food”Equipment Needed: See OT Assessment for all adaptive equipment. Meal Preparation: FORMCHECKBOX Y FORMCHECKBOX NResident assists with meal preparation; if yes, specify: FORMTEXT ?????Resident Preferences: FORMCHECKBOX Y FORMCHECKBOX NExpresses preferences: FORMTEXT ????? FORMCHECKBOX Participates in making choices: FORMTEXT ?????COMMENTS (EXAMPLES: 1) Resident is only provided spoon. Could use training in the use of a fork; 2) Has tendency to throw items; AND 3) Resident could benefit from learning to pour his / her own liquids):Household ManagementSkills:On each line below, enter the number that best represents the resident’s present level of ability for each skill:1. Physical3. Verbal5. Self-Reliant2. Gestural4. IndependentN/A Not Applicable FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Knows when cleaning / organizing of personal space should be done FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Keeps own area tidy FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Makes bed FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Stores and maintains own property FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Dust / wipes surfaces FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Empties trash FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Turns on / off lights FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Turns power on / off (TV, radio, etc.) FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Puts dirty laundry / clothes in hamper FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Brings dirty laundry to laundry room FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Sorts clothing FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Loads / unloads washer and dryer FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Folds clothing FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Hangs clothing FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Puts away own clothing FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Wipes table FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Prepares a sandwich or food item FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Puts centerpiece on table FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Puts placemats on table FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Puts napkins on table FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Puts glasses on table FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Puts silverware on table FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Puts plates / bowls on table FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Selects clothing protector / napkin FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Places clothing protector / napkin in hamper FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Busses dishes from table FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Locks / unlocks lock with key FORMCHECKBOX Y FORMCHECKBOX NUnderstands responsibility of key possession (i.e., does not give key to others, keeps key safe, uses it for intended use. FORMTEXT ?????Tells time: FORMCHECKBOX by event FORMCHECKBOX by timepieceResident Preferences: FORMCHECKBOX Expresses preferences: FORMTEXT ?????COMMENTS / OPPORTUNITIES FOR INCREASING INDEPENDENCE AND RIGHTS (EXAMPLES: 1) Activates electronics with use of a switch; AND 2) Resident can fold clothes but could work on putting them away in his / her drawers):Money ManagementSkills:On each line below, enter the number that best represents the resident’s present level of ability for each skill:1. Physical3. Verbal5. Self-Reliant2. Gestural4. IndependentN/A Not Applicable FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Can identify numbers FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Identifies money from non-money FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Matches coins FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Matches bills FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Identifies coins FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Identifies bills FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Finds appropriate combination of change for items FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Understands exchange FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Understands value of money FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Counts to FORMTEXT ????? (fill in the blank) FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Uses vending machine FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Makes purchase in store / restaurant FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Keeps money on person safely FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Can budget money FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Can keep a resister of money FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Deposits money FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Withdrawals moneyMoney Safety Issues / Risks FORMCHECKBOX Y FORMCHECKBOX NTears money FORMCHECKBOX Y FORMCHECKBOX NMisplaces money FORMCHECKBOX Y FORMCHECKBOX NSwallows moneyResident Preferences: FORMCHECKBOX Expresses preferences FORMCHECKBOX Uses adaptive / assistive device(s). If yes, specify: FORMTEXT ?????COMMENTS (EXAMPLES: 1) Can hand money to cashier but may not wait for change; 2) Knows that money is used to exchange for preferred item(s); AND 3) Understands coins are used to make a purchase from vending machine but does not know the value of money):Safety AwarenessSkills:On each line below, enter the number that best represents the resident’s present level of ability for each skill:1. Physical3. Verbal5. Self-Reliant2. Gestural4. IndependentN/A Not Applicable FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Navigates on uneven surfaces FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Uses sidewalk FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Uses stairs FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Uses a w/c ramp FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Navigates safely through doorways FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Open / shuts door safely FORMCHECKBOX Y FORMCHECKBOX NAbility to live in a unlocked home FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Stays with the group when translocating / outings FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Stops at curb FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Looks before crossing the street FORMCHECKBOX Y FORMCHECKBOX NUnderstands traffic signals / signs FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Uses crosswalk FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Asks for directions FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Communicates where they live FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Fastens seat belt FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Unfastens seat belt when appropriate FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Recognizes unsafe environments, e.g. wet floor / broken furniture FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Avoids aggressive peers FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Responds to directions in a fire / emergency FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Uses emergency numbers (911) appropriately FORMCHECKBOX Y FORMCHECKBOX NRecognizes inedible from edible itemsResident Preferences: FORMCHECKBOX Expresses preferences FORMCHECKBOX Uses adaptive / assistive device(s). If yes, specify: FORMTEXT ?????COMMENTS / OPPORTUNITIES FOR INCREASING INDEPENDENCE AND RIGHTS (EXAMPLE: Resident could increase street crossing skills by consistently stopping and looking both ways. Resident is currently inconsistent with this skill):LeisureSkills:On each line below, enter the number that best represents the resident’s present level of ability for each skill:1. Physical3. Verbal5. Self-Reliant2. Gestural4. IndependentN/A Not Applicable FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Stores and maintains own leisure supplies FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Gathers supplies for specific activity FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Uses leisure supplies appropriately / safely FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Shares leisure supplies FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Spends leisure time with other people FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Uses tabletop games / puzzles, sensory items FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Maintains hobbies / collections FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Uses books / magazines FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Participates in current events FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Decorates environment holiday / seasonal FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Spends time outside FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Participates in exercise or sports FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Operates video games FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Operates karaoke machine FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Operates TV / VCR FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Operates a computer FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Operates IPod / MP3 / CD / radio playerResident Preferences: FORMCHECKBOX Expresses preferences FORMCHECKBOX Uses adaptive / assistive device(s). If yes, specify: FORMTEXT ????? FORMCHECKBOX Participates in preferred leisure locations: FORMTEXT ????? FORMCHECKBOX Y FORMCHECKBOX NExpresses preferences in leisure locations: FORMTEXT ????? FORMCHECKBOX Participates in preferred leisure locations: FORMTEXT ?????COMMENTS / OPPORTUNITIES FOR INCREASING INDEPENDENCE AND RIGHTS(EXAMPLES:1) Resident likes drawing and has own supplies of markers in room; 2) Could work on operating personal radio; AND 3) Resident loves to be outside. Could use more opportunities to choose when to be out):Community Facilities and ServicesSkills:On each line below, enter the number that best represents the resident’s present level of ability for each skill:1. Physical3. Verbal5. Self-Reliant2. Gestural4. IndependentN/A Not Applicable FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Makes appointment for services (i.e., hair , nails) FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Requests to go on community outing FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Displays appropriate behavior for various settings FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Utilizes campus resources (library, activity rooms) FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Attends preferred religious services FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Utilizes community resources (i.e., post office, library, stores) FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Identifies signs (i.e., stop, male / female bathroom) FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Waits in line FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Takes turns FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Uses public transportation FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Orders from a menu in a restaurant FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Discriminates between staff and strangers FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Initiates interaction with community membersCheck the level of support needed to access the community: FORMCHECKBOX Independent FORMCHECKBOX Group FORMCHECKBOX 1-staff FORMCHECKBOX 2-staffResident Preferences: FORMCHECKBOX Y FORMCHECKBOX NExpresses preference of outings FORMCHECKBOX Participates in preferred outings: FORMTEXT ?????COMMENTS / OPPORTUNITIES FOR INCREASING INDEPENDENCE AND RIGHTS (EXAMPLES:1) Resident is capable of waiting appropriately in a line for approximately two minutes; AND 2) Resident should work to sit for longer periods of time, especially in restaurants): Recommendations for HabilitationState in specific functional terms. (Skills the Resident needs to learn based on strengths as well as weaknesses.)Toileting: FORMTEXT ?????Bathing: FORMTEXT ?????Personal Hygiene: FORMTEXT ?????Grooming: FORMTEXT ?????Dental Hygiene: FORMTEXT ?????Dressing: FORMTEXT ?????Easting Skills: FORMTEXT ?????Socialization / Recreation: FORMTEXT ?????Other: FORMTEXT ????? ................
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