Office of Developmental Disabilities
Stabilization and Crisis Unit / Day Program
Assessments / Review date:
Review information:
Client name: / House: / Date:
Communication/skills: / Yes / No / Comments:
Processes received information
A. What is the processing time?
Communicates effectively
A. Verbal communications
B. Written communications(i.e. Letters, etc.)
C. Telephone etiquette
Waits appropriately
Additional comments:
Personal care: / Yes / No / Comments:
Washes hands independently
Combs/brushes hair
Shaves
Brushes teeth
Bathes self
Understands privacy
Additional comments:
Relationships: / Yes / No / Comments:
Close to family members/friends
Calls family/friends
Writes or sends cards to family/friends
Community integration with family/friends
Additional comments:
Adaptive equipment /
Assistive technology: / Yes / No / Comments:
Has hearing aids
Wears glasses
Uses a walker
Uses a wheelchair
Uses KAFO / AFO
Smart phone
iPad
Laptop
Dragon speak knowledge
Additional comments:
Community skills / Yes / No / Comments:
Restaurant
Picks own item from menu
Places own order
Uses picture menu
Physicians
Makes own appointments
Waiting room:
A. Checks in with receptionist
Additional comments:
Home living skills / Yes / No / Comments:
Knows how to dial phone
Knows home address
A. Can write home address
B. Can transcribe it
C. Can say it
Knows home phone number
A. Can write it
B. Can transcribe it
C. Can say it
Knows how to address envelopes
Follows cooking recipes / If yes, how many steps:
Understands how to use measuring spoon/cup
Sets table
Uses oven/stove top
A. Dial
B. Digital
Uses microwave
Uses toaster
Mop
Sweep
Vacuum
Makes bed
Loads dishwasher/washes dishes
Uses washer/dryer
Administers own meds/treatments
Grocery list
A. Checks off list
B. Writes out grocery list
Uses alarm clock
Additional comments:
Transportation/safety / Yes / No / Comments:
Can ride city buses
A. Reads map/schedules / routes
Aware of surroundings
A. Street signs
B. Traffic lights
C. Other vehicles
D. Cue dependent on staff
Rides safely in a vehicle
Additional comments:
NOTE: Yes = Enjoys activity and No = Not a preferred activity
Community preferred activities: / Yes / No / Comments:Shopping
Manicures/pedicures
Visiting others
Going out for coffee
Walks
Picture taking/scrapbooking
Going to the coast/beach
Fishing
Camping
Zoo
Movies
Book stores
Arcades
Dances
Picnics
Attending parties
Swimming
Church
Bowling
Fairs/concerts
Library
Additional comments:
NOTE: Yes = Enjoys activity and No = Not a preferred activity
Daily living preferred activities / Yes / No / Comments:Games/cards
Drawing/coloring/painting
Making decorations
Writing
Reading
Computer
Typing skills
Music/singing and listening to
Hosting parties
Video games(Wii, Xbox, etc.)
Cooking/BBQing
Additional comments:
Education / Yes / No / Comments:
Reading skills
A. Indicate level (elementary or HS)
Writing skills
A. Writes on own
B. Can transcribe
Writes own name
Adding/subtracting skills
Multiplication skills
Budgeting skills
Counts change
Can operate a calculator
Uses Assisted technology (iPod, MP3, etc.)
Additional comments:
Productivity / Yes / No / Comments:
Completes tasks as assigned
A. Independently
B. With cues
Multi-tasks
A. 1 – 3 steps
B. 3 or more steps
Prepares for work independently
A. Gathers supplies
B. Makes lunch
Noise is bothersome
Are re-enforcers needed at work
Learns new assignments quickly
Moves from one job to another easily
Sets priorities while working
Improved productivity when shown how
Handles problems with only occasional help
Handles problems without help
Listens to instructions or corrections attentively
Accepts changes in work assignments
Accepts work assignments and instructions without arguing
Maintains productivity despite changes
Performs satisfactorily in tasks that require variety and change
Expresses likes and dislikes appropriately
Initiate conversations with others (other than staff)
Initiates conversations and interacts with supervisor
Responds appropriately when others initiate conversation
Appears comfortable in social interactions
A. With co-workers
B. With supervisors
Displays appropriate social skills
Gets along with staff while at work
Offers assistance to co-workers when appropriate
Arrives to work on time if they didn’t have staff
Completes their work on time
Departs from work on time
Leaves personal items at home
Lets personal problems interfere with work
Performs work orderly
Returns from break on time
Recognizes unsafe conditions
Able to set up their work area
Additional comments:
Assessment contributors (name and date):
Name: / Date:
BVS1 Signature and date
Updates (name and date):
Name: / Date:
VOC Day Assessment - Client name/initials:______Page 1 of 7DHS 4605 (08/14)