ADULT AUTISM WAIVER QUARTERLY SUMMARY REPORT

Participant Name: / Staff Name:
Provider Agency: / ISP Date:
Service Type (one per form): / Quarter reviewed:
Frequency (e.g., 5x/wk): / Units Per Encounter (e.g., 15-20):
I agree that the information on this form is correct (staff signature): / Date signed:

ISP QUARTERLY OBJECTIVES REVIEWReference monthly progress notes to complete this section.

TIP: Copy and paste the information from the participant’s last monthly (3rd MPN for each quarter) directly into this report.

GOAL PHRASE and CATEGORY
/ OBJECTIVE (condition, behavior, criteria) / QUARTERLY REPORT (in GAS format) / INSTRUCTIONAL DECISION
Example:
Laundry (ADL) / After gathering his dirty clothes from his bedroom, Thom will do his laundry following a task analysis, 8/11 steps completed independently (rest of steps need no more than gesture prompts) for one quarter / Expected Outcome for this quarter: 4/11 steps completed independently (rest of steps need no more that direct verbal prompts
Level of Attainment: --2
Summary:
Thom consistently completed 3 steps independently following the task analysis but still required model prompts for the remaining steps. Although this is an improvement from baseline, he has not met the expected outcome for this month. / C = Continue
R = Revise
D = Discontinue
_X_C __R __D
1. / Expected Outcome for this quarter:
Level of Attainment:
-
Summary: /
__C __R __D
2. / Expected Outcome for this quarter:
Level of Attainment:
-
Summary: / __C __R __D
3. / Expected Outcome for this quarter:
Level of Attainment:
-
Summary: / __C __R __D
4. / Expected Outcome for this quarter:
Level of Attainment:
-
Summary: / __C __R __D
5. / Expected Outcome for this quarter:
Level of Attainment:
-
Summary: / __C __R __D
Goal/Objective # or “NEW” / REASON FOR REVISION, DISCONTINUE or ADDITION / SUGGESTED REVISION or NEW GOAL/ OBJECTIVE

ADDITIONAL CONCERNS TO BE ADDRESSED

(This section Is optional and is to be used to Identify new concerns to be addressed during the next quarter.)

NEW CONCERN
(e.g., “At times, ingredients for crock pot dinners have not been available on scheduled days”) / ACTION TO BE TAKEN
(e.g., “Develop and distribute a weekly schedule at least one week in advance to ensure items are available”) / WHO IS RESPONSIBLE
(e.g., “CS worker”) / EXPECTED COMPLETION DATE
(e.g., “Ongoing”)
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4.

ABOUT THE QUARTERLY REPORT

  • Quarterly Reports are not optional. The Bureau of Autism Services will monitor providers on at least a biennial (every two years) basis to ensure that Quarterly Reports are up-to-date and kept in the participant’s file.
  • Text fields below will expand to accommodate detailed notes.
  • When completed, submit to the participant’s SC no later than the 10th of the month into the next quarter.

1 | PageDCW, 2017/03/06