Because of the Disability This Individual Has Functional Limitations with (Check All That Apply)

R-413 If any limitation is marked in this column and the If there are indicators of serious limitations marked in Face individual requires services, and there are no three functional areas under SD and requires multiple corresponding serious limitations, then the case is services over an extended period of time, then the Sheet assigned to category 6. individual is considered MSD and is assigned to 3. SELF DIRECTION category3. SELF DIRECTION 2. If one or two areas are checked and Dependability Judgment Planning Activities requires Needs adaptivemultiple equipment services to over do tasks an extended period of Following Routine Frequent Changes time, Has then a case the manager/social individual is worker listed due as toa thecategory disability 4. Other Initiating Eligible Activities Making Decisions SD Has difficulty performing tasks without modifications. This Being individual Punctual has functional Being limitations Organized with (check all that This Has individual serious has difficulty Serious concentrating Limitation Areas: on tasks, (check organizing, the indicators and apply) Other______of seriousfollowing limitations through inon each expectations. functional area) ______Requires Requires Multiple detailed Vocational directions Rehabilitation to adequately Services plan activities Over an Requires Services Extended Demonstrates Period ofimpulsivity Time and poor judgment not typically BECAUSE OF THE DISABILITY: BECAUSE seen in individuals OF THE of comparable DISABILITY: age, education, and 1. MOBILITY: 1. experienceMOBILITY: which results in problems or negative Walking Kneeling Twisting Climbing consequencesUnable to move that safely, impact including employment changing body position, without Crouching Stooping Balancing Crawling helpHas orepisodes device. when Explain: assistance/monitoring ______or personal Travel ______assistance is needed to do tasks Other ______TakesOther limitationssignificantly – Explain:longer to ______move about ______Explain: ______Cannot drive due to physical or problems in learning the skill. Explain: ______Other limitations - Explain: ______

2. SELF CARE 2. SELF CARE Eating Child Care Medication Management Requires home modifications to perform self-care tasks in order Hygiene Housekeeping Money Management to get to work Laundry Toileting Shopping Is restricted/limited in the ability to perform average daily living Cooking Dressing Using the Telephone activities to get ready for work Explain: ______Grooming Independent Living Requires a personal assistant, guardian, public administrator, Self-injurious behavior Repeat Hospitalization payee or community support worker for self care skill deficits Other ______in order to work ______Has episodes of repeated hospitalizations and problems with stability Other limitations – Explain: ______4. WORK SKILLS 4. WORK SKILLS Memory Attention Span Does not have work skills usually possessed by individuals of Comprehension Learning Speed comparable age, education, and experience Quantitative Skills Motor Coordination Requires instructions to be paired with multiple strategies, as Manual Dexterity Eye/hand Coordination compared to peers, to learn work skills Manipulates Objects Spatial/Time Management Requires assistive technology, adaptive equipment, or prosthetic to perform work skills Learning Requires a personal assistant or a job coach to learn and/or Other ______perform work skills ______Has difficulty performing fine and gross motor skills required by work tasks Requires extra time to adequately perform tasks Explain: ______Other limitations – Explain: ______

5. WORK TOLERANCE 5. WORK TOLERANCE Stamina Strength Temperature Change Has difficulty tolerating common work environmental factors. Cold/Heat Hazards Noise/Vibrations Explain: ______Fumes/Dust Work Speed High Places Has difficulty tolerating common work psychological stresses. Wet/Humid Environment Explain: ______Sitting Reaching Has difficulty tolerating common physical demands of the job. Explain: ______Chemical Sensitivity Psychological Factors Requires adaptive equipment and/or work schedule to meet Stress Standing job training demands Absenteeism Lifting (lbs., specifics)______Explain: ______Other ______Other limitations – Explain: ______

6. INTERPERSONAL SKILLS 6. INTERPERSONAL SKILLS Cooperation Getting along with others Exhibits emotional behaviors which interfere with work/training Controlling Emotions Tact/diplomacy with co workers and managers Understanding Social Cues Accepting Supervision Requires monitoring, behavior management, accommodations Social Withdrawal or adaptations, not typically made for other employees to develop or maintain working relationships. Other ______Lacks insight into self that results in a lack of tact/diplomacy which creates difficulties in maintaining work relationships. Other limitations – Explain: ______

7. COMMUNICATION 7. COMMUNICATION Speaking Reading Hearing Cannot hear/understand ordinary speech Writing Interviewing Has difficulty reading or writing beyond simple sentences Other ______typically found in 6th grade level and below and in comparison ______to peers of equivalent age. Requires an interpreter or other hearing accommodation to obtain employment Requires a reader or other accommodation to read in order to obtain employment Cannot readily be understood on first contact Other limitations – Explain: ______

Revised 12/2013