1. 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) WAITING LIST ASSESSMENT STATE OF CONNECTICUT Name: _________________________________________________________ Completed by: _______________________________________ Date: __________________ Comment: ______________________________________________________________________ Pg 1 of 2 8/4/00 B. ACTIVITIES OF DAILY LIVING 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) 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. Attachment C

2. C. HEALTH AND MEDICAL CARE 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) 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. D. CHALLENGING BEHAVIOR 1. Independent (has no special support needs in this area, only experiences rare or minor incidents, does not require staff or family member supervision to prevent dangerous or inappropriate behavior) 2. Moderate Support Needed (occasional incidents of inappropriate behavior, may sometimes require oversight or supervision, responds to verbal redirection, can exhibit self-control most of the time) 3. Requires Supervision and Assistance (behavioral incidents are periodic and potentially dangerous to self or others, requires general observation, requires occasional physical guiding or intervention to prevent harm to self or others, not able to exhibit self control most of the time) 4. Comprehensive Support (behavior incidents are very frequent and/or seriously health or life threatening, requires in-sight supervision at all times, physical intervention may require 1-2 person restraint or removal from area) Includes the range of behaviors that jeopardize self or others, including: self injury, aggression to others, property destruction, criminal behaviors, sexual assault, pica, severe socially inappropriate behavior. WAITING LIST ASSESSMENT E. SAFETY 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) 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). Pg 2 of 2 8/4/00