Free Assessment Worksheet for Natural Residential Setting - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Long Term Care F-20817 (Rev. 08/2008)

STATE OF WISCONSIN Completion of this form is Required by Section 49.77(3s)(b), Wis. Stats

ASSESSMENT WORKSHEET FOR NATURAL RESIDENTIAL SETTING
Name ­ SSI Recipient (Last, First, MI)

NOTE: If a person resides with a spouse or is a minor child residing with a legal parent, only services received/needed when the spouse or parent is away from the residence for purposes of employment or which the spouse or parent is physically or mentally incapable of providing count toward the 40-hour requirement (s. 49.77(3s)(b) 1 and 2). SUPPORTIVE HOME CARE (SHC) If the person requires the assistance of another person in the following areas, enter the approximate hours per month.
Care of the Person 1. Eating meals 2. Changing position in bed 3. Transferring from bed/ wheelchair 4. Using the toilet and/or controlling bladder or bowel 5. Personal mobility 6. Bathing, grooming/dressing 7. Medical support Chore 12. Grocery shopping/food preparation/clean-up 13. Housework/laundry 14. Yard work/snow shoveling TOTAL Monthly Hours of SHC 8. Planning/accessing leisure time activities 9. Finance/bill paying 10. Physically accessing medical care 11. On-site supervision 16. Other--specify: Other Respite 15. Respite

DAILY LIVING SKILLS TRAINING (DLST) If the person needs training in the following areas, enter the approximate number of hours per month.
1. Personal hygiene, grooming, and dressing 2. Planning/preparing food/clean-up 3. Laundry activities 4. Housekeeping 5. Budgeting and/or using the banking system 6. Purchasing necessities: food/clothes 7. Socialization skills/leisure activities 8. Developing appropriate sexual behaviors 9. Parenting skills/family relationships 10. Accessing public/private transportation 11.BIRTH to 3 program for children 12.Medical support 13.Consumer training 14.Other--specify: TOTAL Monthly Hours of DLST

If the total hours of SHC and DLST needed are 40 or more hours per month, the person is eligible for SSI-E.

Keep in agency case file