SUPPORT NEEDS

1
STATE OF CONNECTICUT
Attachment C
Pg 1 of 2 8/4/00
WAITING LIST ASSESSMENT
Name ___________________________________________
______________ Completed by ___________________
____________________ Date __________________ C
omment ________________________________________
______________________________
SUPPORT NEEDS
Complete the following assessment using the
following ratings for support and supervision
needs.
1 Independent (Requires no direct assistance.
May require occasional prompts or adaptive
aids. No special staff or personal assistance
required to assure safety) 2 Moderate Support
Needed (Sometimes needs staff support or
assistance to complete the activity or assure
safety.) 3 Requires Supervision and Assistance
(Usually requires staff support, assistance or
ongoing training to complete the activity or
assure safety.) 4 Comprehensive Support and
Ongoing Supervision Needed (Always requires
staff support, assistance or training to complete
the activity. Safety of self or others is
jeopardized without the immediate presence of
staff supervision and assistance.)
A. LIFT/TRANSFER AMBULATION

1. Independent (ambulatory, no special mobility
   needs, or able to lift or transfer self, can
   mobilize wheelchair by self)
2. Moderate Support Needed (may sometimes require
   partial physical assistance to ambulate or
   mobilize wheelchair)
3. Requires Supervision and Assistance (usually
   requires at least one person to lift/transfer,
   cannot ambulate or mobilize wheelchair without
   assistance)
4. Comprehensive Support (requires two or more
   people to lift/transfer, does not ambulate or
   mobilize wheelchair by self, requires special
   schedule or positioning or re-positioning)

B. ACTIVITIES OF DAILY LIVING
Includes the range of self-help and daily living
skills associated with adult living, including
cooking and meal preparation, grooming and
hygiene, dressing and clothing selection,
bathing, toileting, laundry, house cleaning,
money management and shopping.

1. Independent (able to complete most tasks by
   self, may need occasional reminders or prompts,
   may need occasional staff or family direction or
   observation, teaching new skills relies primarily
   on verbal or sign instruction.)
2. Moderate Support Needed (requires verbal prompts
   for some tasks, may sometimes require partial
   physical assistance to complete some tasks - but
   able to complete others without assistance.)
3. Requires Supervision and Assistance (usually not
   able to complete most of the tasks by self, needs
   partial physical assistance to complete most
   tasks, wide variation in level of skill)
4. Comprehensive Support (cooperates or
   participates in tasks minimally, needs physical
   assistance all the time to complete tasks)

2
Pg 2 of 2 8/4/00
WAITING LIST ASSESSMENT
C. HEALTH AND MEDICAL CARE
Includes the range of chronic medical conditions
requiring treatment by a physician and oversight
by a nurse or personal assistant, including those
that require the use of prescription medications
on an ongoing basis.

1. Independent (has no significant or chronic
   medical conditions, able to take medications by
   self or with minimal staff prompting or
   supervision)
2. Moderate Support Needed (has minor medical
   problems that are not life threatening, able to
   take medication with staff assistance and/or
   supervision)
3. Requires Supervision and Assistance (has a
   serious medical condition that requires close
   monitoring and supervision, requires staff or
   family members to administer medications)
4. Comprehensive Support (has a very serious or
   life threatening medical condition that requires
   specialized treatments and close specialized
   observation by a nurse or other trained
   professional, does not participate in monitoring
   of medical condition or provision of treatment)

E. SAFETY
Includes the range of behaviors required for self
protection, including the ability to recognize
dangerous situations, respond to emergencies and
call for help (e.g., 911).

1. Independent (able to recognize and respond to
   medical emergencies or serious injuries, can call
   911 in appropriate situations, can evacuate
   without assistance)
2. Moderate Support Needed (recognizes when to call
   or ask for staff or family assistance if ill or
   injured, can call 911 in appropriate situations,
   understands alarms and evacuation procedures)
3. Requires Supervision and Assistance (may not be
   able to identify serious injuries or medical
   emergencies without assistance, cannot
   consistently call 911 in appropriate situations,
   needs prompts to evacuate)
4. Comprehensive Support (requires staff monitoring
   for injuries or medical emergencies, unable to
   seek assistance in dangerous situations, requires
   staff or family supervision and physical
   assistance to evacuate)