FUNCTIONALCOMMUNITY ASSESSMENT
INDIVIDUAL’SNAME
STAFFPERSONCOMPLETINGASSESSMENT
DATE ASSESSMENTCOMPLETED
A.MEDICATION
1. Doesthispersontakeprescribedmedication? Yes No
(IfYES,completeremainingquestionsinSectionA. IfNO,respondtoquestion
2only and proceed to Section B.)
2. How will the person obtainandself-administerover-the-countermedicationsnot prescribed by a physician?
3.Can the person independently place an order forandobtainaprescriptionfromtheir physician?
YesNo
IfNO,describesupportortrainingneeded:
4.Canthe person independently notify their physicianand/orpharmacistofallover- the-countermedicationsbeingused? Yes No
IfNO,describesupportortrainingneeded:
5.Check which one of the following apply:
Individual is capable of handling his/her own medications without supervision.
Individual will need supervision with the self-administrationofmedication according to Developmental DisabilitiesProgramPolicyDirective#01-01.
Explanation:
Whichstaffwillbeprovidingsupervision?
Individualwillneedstafftoadministerhis/hermedicationaccordingto
DevelopmentalDisabilities ProgramPolicyDirective#01-01.
Explanation:
Whichstaffwillbeadministeringmedication?
6.Can the individual independently take proper medicationstowork,onvacation,orto activitiesawayfromhome? Yes No
IfNO,describesupportortrainingneeded:
B.NUTRITION
1.Canthepersonplanhis/herownmenus? YesNo
IfNO,describesupportortrainingneeded:
2.Isthepersononaspecialdietmonitoredbyaphysician? YesNo
If YES, describe the diet:
Explain medical condition that prompted the diet:
3.Can the person independently purchase his/herongroceries? YesNo
IfNO,describesupportortrainingneeded:
4.Canthepersonindependentlypreparehis/herownmeals? YesNo
IfNO,describesupportortrainingneeded:
5.Canthepersonindependentlysetthetablefordining? YesNo
IfNO,describesupportortrainingneeded:
6.Canthepersoneathis/hermealswithoutassistance? YesNo
IfNO,describesupportortrainingneeded:
C.SEXUALITY
1.Can the person differentiate between a casual relationship and an intimate relationship?
Yes No
Describeanyareasofconcern:
2.Does the person have understanding ofsexuallytransmitteddiseases(e.g., HIV/AIDS,etc.)?
Yes No
IfNO,describesupportortrainingneeded:
3.Isthepersonawareoftheirrightto say,“No”? (Doesthepersonunderstandthe differencebetweenconsensualandnon-consensualsex?) Yes No Describeanyareasofconcern:
4.Ifapplicable,doesthepersonhaveafunctional understanding of protected sex and birth control?
Yes No
Describeanyareasofconcern:
D.FIRSTAID
a. Canthepersonadministerbasicfirstaidtohimself/herselfandaccess/useafirst aid kit?
YesNo
IfNO,describesupportortrainingneeded:
E.SERIOUS ACCIDENTS AND ILLNESS
1.Can the person recognize when he/she is ill orinjuredandrequiresoutsidehelpor attention?
YesNo
IfNO,describesupportortrainingneeded:
2.Can the person access the followingemergencyassistanceifneeded: Dial911? Yes No
AccessHab. Services’24-hourpager? YesNo
Summonaroommateorneighbor? YesNo
IfNO,describesupportortrainingneeded:
F.SEVERE WEATHER AND OTHER NATURAL DISASTERS
1.Doesthepersonknowhowtorespondtosevereweatherandothernatural disasters?
YesNo
IfNO,describesupportortrainingneeded:
G.FIRE AND SAFETY CONSIDERATIONS
1. Didthepersondemonstratetheproperuseofafireextinguisher?YesNo
2. Canthepersonself-evacuatethroughanaccessibleexit? YesNo
IfNO,describesupportortrainingneeded:
3. Doesthepersonknowwheretogoiftheyneedtobetemporarilyrelocated?
YesNo
IfYES,where?
IfNO,describesupportortrainingneeded:
H.PERSONAL CARE
1. Isthepersonindependentinhis/herselfcare? YesNo
IfNO,describespecificareasofsupportortrainingneeded:
IfNO,willthepersonneedpersonalcareassistanceorin-homesupports?
YesNo
IfYES,havetheseservicesbeenarrangedbythesupportcoordinator?
YesNo
I.HOUSEHOLD MAINTENANCE/MANAGEMENT
1.Isthepersonabletoindependentlymaintainhis/herhome? YesNo
IfNO,describespecificareasofsupportortrainingneeded:
2.Canthepersonmonitorhis/herhouseholdforbasicrepairsneededandsafety concernssuchasleakyfaucets,frayedelectricalcords,etc.? Yes No
IfNO,describespecificareasofsupportortrainingneeded:
3.Can the person contact the landlord and/orservicetechniciansforneededrepairs?
YesNo
IfNO,describesupportortrainingneeded:
4.Doesthepersonknowhowtosecureexteriordoorsandwindows,etc.atnightor whenhe/sheleavesthehouse? Yes No
IfYES,dotheyconsistentlyremembertodoso? YesNo
5.Isthepersonawareoftheirrighttoaskwouldbevisitorstoidentifythemselves andtorefuseentryiftheysodesire? Yes No
J.MONEYMANAGEMENT
1.Canthepersonmakesimplepurchases(upto$10)? YesNo
2.Canthepersoncountchange? YesNo
3.Canthepersonwritecheckstopaybillsormakepurchases? Yes No
4.Canthepersonsigntheirchecks? YesNo
5.Canthepersonmakebanktransactionsindependently? YesNo
IfNO,describeareasofconcern:
6.Canthepersonprepareabasicbudget? YesNo
7.Canthepersonfollowabasicbudget? YesNo
IfNO,describeareasofconcern:
8.Can the person exercise appropriate assertivenesswhenothersaskhim/herfor some/alloftheirmoney? Yes No
IfNO,describeareasofconcern:
9.DoesthepersonrequireHabilitativeServicestoserveastheirfiscalagent?
YesNo
IfYES,justify:
K.COMMUNITYMOBILITY
1.Whatwillbetheperson’sroutinemethod of mobility in the community?
2.Cantheyaccesstransportationservicesindependently? YesNo
IfNO,describeareasofconcern:
3.Canthepersoncrossstreetssafely? YesNo
IfNO,describeareasofconcern:
4.Doesthepersonpracticecommunity safety(awarenessofothers,handling strangers,etc.)?
YesNo
IfNO,describeareasofconcern:
L.INTERPERSONAL / RECREATION / LEISURE
1.Can the person engage in casual, friendlyconversationinpersonwithothers?
YesNo
IfNO,describeareasofconcern:
2.Canthepersoncallpeopleonthetelephone? YesNo
3.Can the person plan/participate in theirowncommunityactivities(shopping, movies,shows,sportingevents,healthclubs,parks,etc.) Yes No Whichactivitiesdotheyparticipateinroutinely?
Describeareasofconcern:
4.Canthepersonmanagetheirownfreetime? YesNo
Describeareasofconcern:
OTHERTHINGSTOKNOW:
DATE / NOTES/UPDATES / INITIAL