Habilitation Data Collection Form #5

HABILITATION DATA COLLECTION FORM #5 The purpose of this document is to record the progress of the client in the areas of functional skill acquisition; according to the ISP, agreed upon & determined by the team. Chart the information as directed by the criteria of the objective(s). Submit monthly with the MONTHLY HABILITATION PROGRESS REPORT FORM #6. Directions: Enter the year. In the far Left Column: Enter a checkmark () next to the step(s) Enter the Skill. Enter the charting date, each day you provide service and record you are Focusing on. Enter the measurable objective as written in the Skill Plan. data. Enter  in the box next to the step(s) that have met the objective Enter the Start Date: The date you begin training the skill. Note: Habilitation Providers record data on each objective at lease criteria in Outcome (Skill displayed/ observed) Level of Enter the Target Date: The date that you expect the person will once during training on one or more step(s) of a skill. Assistance, Level of Completion & Time Frame. meet the criteria of the objective. Enter the Letter corresponding to the Level of Assistance provided To determine that the person has met the objective & completed Enter the steps of the skill according to the Skill Plan (brief and enter the Symbol corresponding to the Level of Completion for the step(s), apply the objective criteria to each step. description). the focus step(s) practiced in split box below the charting date. Note: Leave this column blank if not a focus step or a Completed step. DATA KEY: I = Independent  = Met (Step(s) meet Objective Outcome and the Level of Assistance stated) LEVEL OF V = Verbal Cue/Sign LEVEL OF  = Partially Met (Step(s) meet Objective Outcome providing a greater level of ASSIST G = Gesture, Verbal Cue/Sign COMPLETION assistance that stated) M = Model, Gesture & Verbal Cue/Sign ANCE O = Unmet (Step(s) have not met Objective outcomes, training opportunity offered) L = Light Physical Assist, Model, Gesture, Verbal Cue/Sign N/A Step(s) that will always require more assistance than stated in the Objective. P = Full Physical Assist (hand over hand guidance) Model, Gesture, (L.C.) Enter N/A next to the step and draw a line through the charting boxes. (L.A.) Verbal Cue/Sign

CLIENT SUPPORT COORDINATOR PROVIDER DATE SKILL(#1) Objective:

START DATE: TARGET DATE: Date:  or  STEPS Yr. L. A. L.C. L. A. L.C. L. A. L.C. L. A. L.C. L. A. L.C. L. A. L.C. L. A. L.C.