Individual Specific Training Form (Addendum B)

Individual Specific Training Form (Addendum B)

Direct Support Staff: __________________________________________________________________

Family Living Provider ____________________________ Date ________________

Person Served _________________________________________________________

Safety

Is there a fire escape plan in the home? If so, where? ____________________________________

What assistance would the individual need in case of a fire? _______________________________

_______________________________________________________________________________

Does the individual need assistance with knives or cutting food? ____________________________

Are there any chewing or swallowing difficulties? _______________________________________

What are the individual’s street safety skills? ___________________________________________

Is assistance required for mobility? ___________________________________________________

Preference and Choice

Review of CDE, Inc. Individual Preference Assessment.___________________________________

If no preference assessment, what are the individual’s likes and dislikes? _____________________

________________________________________________________________________________

Does the individual participate in regular community activities? What are they? _______________

_______________________________________________________________________________

Are there activities that the individual or guardian would like to see avoided? _________________

_______________________________________________________________________________

Is the Individual able to be alone for any periods of time (if yes, for how long)? _________________

_________________________________________________________________________________

Does the Individual have alone time? ___________________________________________________

Health

Does the individual take medication? _____________

If so, what are the medications, purpose, dose & side effects? (A current MAR can be attached to this training form) ____________________________________________________________________________

_________________________________________________________________________________

Does the individual have any allergies? _________________________________________________

Are there any other health concerns? ___________________________________________________

Who are the individual’s doctors and other health care professionals? _________________________

_________________________________________________________________________________

Are there any special dietary or nutritional needs? ________________________________________

Does the individual have a specific mealtime plan? _______________________________________

Are there any Physical or Occupational Plans? ___________________________________________

Is there a Healthcare Plan. (Required if HAT score is 4, 5, or 6)______________________________

Are there any Speech Therapist Plans? _________________________________________________

Behavior Supports

Does the individual have a behavior plan? If yes, please review it.___________________________

Is there a crisis intervention plan? _____________________________________________________

Are there any behavioral issues? ______________________________________________________

If yes, what techniques work or don’t work when supporting the individual.____________________

Communication

How does the individual communicate? ________________________________________________

What physical, mental and environmental factors influence the individual’s behavior? ___________

________________________________________________________________________________

Are there any personal space and touch preferences or issues? ______________________________

________________________________________________________________________________

If yes, what techniques work or don’t work when supporting the individual.____________________

________________________________________________________________________________

Are there any assistive Technology aids or a communication dictionary? ______________________

Miscellaneous

Who is the guardian if the individual is not his/her own guardian? ___________________________

What are the individual’s motivators? _________________________________________________

_______________________________________________________________________________

What is the best time of day for learning? ______________________________________________

What are the individual’s strengths and capabilities? ______________________________________

________________________________________________________________________________

Review Emergency phone numbers.___________________________________________________

Is assistance required for bathing or personal hygiene? ____________________________________

Is there anything important on the Addendum B or in the ISP that has not been covered? _________

________________________________________________________________________________

Family Living Providers, please do not let this form restrict you. If there is important information that needs to be relayed and is not covered by this form then be sure to include it in the training.

_____________________________________ ___________________

Family Living Provider Signature Date

_____________________________________ ___________________

Direct Support Staff Date

______________________________________ ___________________

CDE, Inc. Representative Date

RECORD OF TRAINING ON INDIVIDUAL SPECIFIC TRAINING

I, ________________________________, certify that on the date indicated below I received Case de

Esperanza, Inc. in-service training regarding INDIVIDUAL SPEC9IFIC TRAINING.

____________________________________ _________________________

Trainee Date

____________________________________ _________________________

CDE, Inc. representative Date