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#ElementsPoints per element
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PART 1 - GENERAL INFORMATION
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1Required identifying information - 4 points
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a. Focus person’s pseudonym or initials
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b.Focus person’s age1 point for A-D
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c. Referral source & contacts
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d. Facilitator name
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eFocus person’s gender identification
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f.Focus person’s preferred pronouns are noted 1 point for E-H
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g.Focus person’s person first or identity first language is honored as observed with the team
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h.Legal authorization to make their own decisions is explained (i.e. supported decision maker, legal guardian, person makes own decisions)
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i.The focus person’s preferred method of communication is documented.1
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PART 2 - PERSON'S HISTORY AND CURRENT INFORMATION
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2Focus person’s strengths: What others like and admire about the person - 2 points
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a.Includes person's strengths, including skills1
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b.Describes the person's personality characteristics1
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3Brief history of the focus person’s life - 12 points
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a.1Current residence is described 1
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a.2Past residences are described. Indicates if there are no past residences. 1
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b.Biological family history and current status is described 1
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c. Educational history is described1
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d.Previous support services are documented1
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e.1Dream statement is included in plan (1 point) and focus person's involvement in the statement (1 point) is described 2
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e.2How the person’s life lines up with what they want life to be like (dream statement) is explained.1
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f.1History of person's social life and community connections are described 1
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f.2History of daytime engagement is described1
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g.Adaptive equipment and necessary accommodations are described. 1
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h. Person's culture/heritage is described. 1
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4Person centered tools and approaches
This section is about explaining what is Important To/For the person, plus at least 3 additional person-centered approaches are conducted with the team and outcome is documented. (Donut, 4+1, Good Day/Bad Day, Reputations/Reframing, two-minute drill, what’s working/Not working, relationship mapping, Learning log, Rituals and Routines, communication chart, matching staff, MAPS, PATH, CtLC, etc.) - 12 points
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a.What is important to (1 point) and for (1 point) the person is described. A description of how important to and for are currently balanced is included. (1 point)3
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b.Person Centered approach #1: The tool, (1 point) how it was used (1 point) , and the result of using the approach (1 point) are described3
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c. Person Centered approach #2: The tool, (1 point) how it was used (1 point) , and the how (1 point) are described3
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d. Person Centered approach #3: The tool, (1 point) how it was used (1 point) , and the result of using the approach (1 point) are described3
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5Current Important places and people for the focus person - 3 points
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a.Important places during person's daytime engagement, e.g. school, work, are described. If the person has no daytime engagement, that is indicated1
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b.Important places in the community for the focus person are described 1
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c. Important people for the focus person and opportunities to interact are described1
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6Preference assessment information - 3 points
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a. How the person enjoys spending their time is described1
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b.The method of gathering preference information is described1
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c. The results of a preference assessment are described1
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7Opportunities for choice in the focus person’s current environment are described1
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8Issues of focus person’s control over their current environment are documented1
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9Health and physiology issues - 7 points
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a. Childhood health and development is discussed. It is noted if childhood information is not available1
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b.Etiology (if appropriate) and diagnoses or absence of diagnosis of physical health are described 1
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c. Etiology (if appropriate) and diagnoses or absence of diagnosis of mental health are described 1
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d. The plan includes a description of how the focus person’s health influences their current life1
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e.Medications are listed (If applicable. If no medications are used, it should be noted) (1 point) and their intended purpose (1 point)2
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f.Potential effects of medication influencing behavior are described. If no medications or side effects are evident, it should be noted1
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10Trauma - 2 points
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a. The plan documents whether the person has experienced trauma. If the person did not experience trauma, it is noted1
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b.How trauma impacts the focus person’s behavior is documented. If trauma does not impact behavior, it is noted1
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11Mobility - 2 points
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a. The person’s ability to move around is described1
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b.The person’s transportation access is discussed1
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12Current Weekly Schedule - 5 points
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a. The plan describes a weekly schedule of what the person does daily (1 point) and the times of day the events occur (1 point) 2
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b.The plan includes the focus person's comments and/or participation regarding their current activities1
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c. The plan documents the focus person’s perspective on whether they want to continue to participate in current activities1
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d. The plan describes the predictability of the focus person’s schedule1
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15Reason For Referral - 4 points
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a. The reason why PBS services are being requested is documented1
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b.Behavior of concern is described1
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c. Impact of the behavior on the focus person’s (1 point) and team’s (1 point) day -to-day life is described2
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16Positive Behavior Support Team - 12 points
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a. Focus person’s choice of team participants is described1
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b.Roles of team members are described (excluding PBS Facilitator) 1
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c. Team’s positive characteristics are described1
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d. Strategies to address team’s challenges and obstacles are described1
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e.Strategies used to give the focus person control in team meetings are described1
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f.Prior to the design of the intervention, the plan includes a description of team’s agreement (1 point), focus person’s agreement (1 point) on behavior of concern, and commitment to address it by signed consent (1 point) 3
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g.The risks (1 point) and benefits of services(1 point) are described2
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h.The plan describes the role of the PBS Facilitator (1 point)1
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i.The plan documents whether needed accommodations were provided for team members1
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PART 3 – ASSESSMENT
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17Functional Behavior Assessment 2 points
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aIt is documented that FBA was conducted in location where person uses services1
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b. The plan documents that the FBA is within 6 months of current date 1
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18Indirect assessment - 4 points
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a. The plan describes that record reviews were conducted.1
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b.The plan describes that support team was interviewed1
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c. The plan describes the focus persons's involvement in the interview 1
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d. The plan documents lists what assessment tools were used.1
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19Direct Assessment from observations - 3 points
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a. Direct assessments are described in the plan.1
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b.Raw data are included in the plan.1
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c. Method of measurement of behavior is documented and explained in plan.1
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20Operational Definition of the Behavior of concern - 6 points
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a. Behavior (s) of concern’s definition in operational terms 1
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b.Includes method of measurement for behavior(s)1
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c. Intensity is described1
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d. Risks and negative outcomes are described1
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e.Examples of the behavior are included 1
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f.Non examples of the behavior are included 1
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21Items included in Functional Behavior Assessment (FBA) - 5 points
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a. Setting events/motivating operations for each behavior are described 1
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b.Antecedents are described for each behavior 1
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c. Consequences are described for each behavior 1
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d. Description of the functions of the behavior match to accepted operant functions1