Community Based Situational Assessment
Community Based Situational Assessment (CBSA)* definition:A CBSA is utilized to assess a client’s skills, abilities, strengths, barriers, and need for long term support in a competitive work environment. FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ? In a CBSA, the Employment Specialist would determine what, if any additional support might be needed for the client to be successful. The Vocational Rehabilitation Counselor (VRC) may be reasonably certain a client can do well in a specific job, but may be unsure of what services might be necessary to best insure the client’s success over time. It is often necessary to evaluate the client’s abilities to meet those demands by observing him/her in the actual work environment.NOTE: A CBSA also provides the employer an opportunity to see a client “in action”.A job offer may be an outcome of the CBSA, in which case, the information gathered will be utilized to create the Individualized Plan for Employment (IPE). Required Information: To be completed by Employment Specialist (ES):Client Name: FORMTEXT ?????Report Date: FORMTEXT ?????Referring VRC: FORMTEXT ?????CRP/Agency: FORMTEXT ?????Employment Specialist: FORMTEXT ?????Job Coach: FORMTEXT ?????Purpose of Service: FORMTEXT ?????Assessment Site: FORMTEXT ?????Address: FORMTEXT ?????Assessment Date(s): FORMTEXT ?????Assessment Schedule: FORMTEXT ?????Client Job Position (Title): FORMTEXT ?????Total number of hours client worked during this assessment:Daily: FORMTEXT ?????Weekly: FORMTEXT ?????Total: FORMTEXT ?????Number of on-site job coaching hours required by client: FORMTEXT ?????Number of direct support hours provided to client: FORMTEXT ?????Responsibilities of client’s job position: FORMTEXT ?????Vocational CapacityThe Vocational Capacity assessment identifies the client’s ability to carry out the required tasks of the job. Please indicate which factor or factors are required to perform a specific job/task function. Please note in the comment section the client’s performance and any accommodations which may be needed. FORMTEXT ? FORMTEXT ? FORMTEXT ? Standing: FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX ConstantComments: FORMTEXT ?????Walking: FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX ConstantComments: FORMTEXT ?????Sitting: FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX ConstantComments: FORMTEXT ?????Driving: FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX ConstantComments: FORMTEXT ?????Lifting: FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX ConstantComments: (above waist, below waist, pounds) FORMTEXT ?????Carrying: FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX ConstantComments: (pounds, distance) FORMTEXT ?????Pushing: FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX ConstantComments: (pounds) FORMTEXT ?????Pulling: FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX ConstantComments: (pounds) FORMTEXT ?????Climbing: FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX ConstantComments: (ladders, stairs, scaffolds, ramps, poles) FORMTEXT ?????Balancing: FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX ConstantComments: FORMTEXT ?????Stooping: FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX ConstantComments: FORMTEXT ?????Kneeling: FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX ConstantComments: FORMTEXT ?????Crouching: FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX ConstantComments: FORMTEXT ?????Reaching: FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX ConstantComments: (overhead, chest level) FORMTEXT ?????Gross Motor Skills: FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX ConstantComments: FORMTEXT ?????Fine Motor Skills: FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX ConstantComments: FORMTEXT ?????Communication: FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX ConstantComments: (oral/verbal, gestural, signing/verbal) FORMTEXT ?????Hearing Required: FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX ConstantComments: (regarding coworkers, phone, public) FORMTEXT ?????Exposure to weather: FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX ConstantComments: FORMTEXT ?????Exposure to Cold Temperatures: FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX ConstantComments: FORMTEXT ?????Exposure to Hot Temperatures: FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX ConstantComments: FORMTEXT ?????Exposure to Wet and/or Humid: FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX ConstantComments: FORMTEXT ?????Noise Intensity Level: FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX ConstantComments: (quiet, moderate, loud, very loud) FORMTEXT ?????Vibration: FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX ConstantComments: FORMTEXT ?????Atmospheric Conditions: FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX ConstantComments: (odor, dust, mist, gas, fumes) FORMTEXT ?????Mechanical Parts Hazard: FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX ConstantComments: FORMTEXT ?????Toxic/Caustic Chemical Hazard: FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX ConstantComments: FORMTEXT ?????Other Environmental Conditions: FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX ConstantComments: FORMTEXT ?????Protective Clothing: FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX ConstantComments: FORMTEXT ?????Near Acuity: (under 20 inches) FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX ConstantComments: FORMTEXT ?????Far Acuity: (over 20 feet) FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX ConstantComments: FORMTEXT ?????Depth Perception: FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX ConstantComments: FORMTEXT ?????Color Vision (Need to distinguish colors): FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX ConstantComments: FORMTEXT ?????Lighting Level: FORMCHECKBOX Dim FORMCHECKBOX Bright FORMCHECKBOX FluctuatingComments: FORMTEXT ?????Identify client’s primary employment strengths based on performance: FORMTEXT ?????Identify client’s primary barriers to employment based on performance: FORMTEXT ?????Work Quality Observation FORMTEXT ?Work Pace: FORMCHECKBOX Fast FORMCHECKBOX Moderate FORMCHECKBOX SlowComments: FORMTEXT ?????Work Schedule: FORMCHECKBOX Intermittent FORMCHECKBOX SteadyComments: FORMTEXT ?????Stamina: FORMCHECKBOX High FORMCHECKBOX Medium FORMCHECKBOX LowComments: FORMTEXT ?????Arrival to Work: FORMCHECKBOX Early FORMCHECKBOX Timely FORMCHECKBOX LateComments: FORMTEXT ?????Departure from Work: FORMCHECKBOX Early FORMCHECKBOX Timely FORMCHECKBOX LateComments: FORMTEXT ?????Appropriate Breaks: FORMCHECKBOX Always FORMCHECKBOX Sometimes FORMCHECKBOX NeverComments: FORMTEXT ?????Ability to Recognize Surroundings FORMCHECKBOX Always FORMCHECKBOX Sometimes FORMCHECKBOX NeverComments: FORMTEXT ?????Ability to work safely and independently FORMCHECKBOX Always FORMCHECKBOX Sometimes FORMCHECKBOX NeverComments: : FORMTEXT ?????Interpersonal Interaction FORMTEXT ?Co-workers: FORMTEXT ?????Supervisor: FORMTEXT ?????Public: FORMTEXT ?????Customers: FORMTEXT ?????Client’s reaction to authority figures: FORMTEXT ?????Ability to accept and act on constructive criticism: FORMTEXT ?????Do you see the need for supported employment services (on and/or off-site)? FORMTEXT ? Please detail reasons for recommendations, including number of hours of long term support recommended for this job position: FORMTEXT ?????Based on this assessment, do you believe this worksite/type of employment is a good fit for this client? Please explain: FORMTEXT ?????Additional notes if applicable: FORMTEXT ????? FORMTEXT ?????Employment Specialist SignatureDate ................
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