Questionnaire Situational Information Version 4 - …

1 Revised 5-21-15 Rule Florida Questionnaire Situational Information Version EFFECTIVE 2-15-08 To be used by Certified Administrators Only Produced for the Person s Name Area Date Florida Questionnaire for Situational Information Version Purpose and Use of this Questionnaire The Questionnaire for Situational Information is a Questionnaire designed to gather key Information about a person that will describe his or her life situation for the purpose of planning supports over a 12*month period.

2 These descriptions reflect a person s needs for assistance in key life roles and areas of daily activity. The first portions of the Questionnaire are entitled Life Changes and Community Inclusion. These areas of inquiry focus on a person s need for assistance in order to adjust to life changes while living, working, fulfilling valued roles, and participating in his/her community. The next portion of the Questionnaire is titled Functional Status and focuses on a person s need for assistance during the normal course of a routine day, including sight, hearing, communication, and ambulation.

3 Another portion is titled Behavioral Status and focuses on any major behavioral issues that might require assistance and intervention. The final portion is titled Physical Status and focuses on health and physical concerns, including medical conditions that an individual experiences and medications taken on a routine or emergency basis. Together these life areas are explored and rated to generate Information about types and levels of support the person may require now and in the near*term future. The Questionnaire for Situational Information is a component of a holistic approach to the development of a support plan that meets the needs of the individual.

4 As support plans are developed for each person, the preferences of the individual as well as Information from the Personal Outcome Measures and other Information sources blend together to achieve a unified and collaborative approach for each person served by the Agency for Persons with Disabilities (APD). Personal Information gathered by this Questionnaire is confidential and is to be respected and kept private. Non*identifying data gathered by the Questionnaire may be used in generating legislative budget requests and estimating a range of costs associated with a reasonable approach to amelioration of a developmental disability.

5 The development of the Questionnaire for Situational Information has included the review and perspective of national experts in services and supports to people with developmental disabilities. It is built on other existing screenings and assessments from other states that identify major barriers to good health, safety, and quality of life. This Questionnaire will be administered in the language understood by the interviewee. In addition, the administration of this Questionnaire will be performed by persons who are properly qualified, have received training, and authorized to do so.

6 In every instance, the gathering of personal Information will include an observation of and a face*to*face interview with the individual with a developmental disability, the individual s guardian, and the individual s family. In addition, the following should occur: Interviews with the individual s caregivers and/or health care personnel, as appropriate Review of the individual s records including recent assessments and progress notes from medical records, school records, previous support plans, and relevant Information from other collateral sources, as appropriate.

7 The Questionnaire for Situational Information will be administered at the time of eligibility determination for the Agency for Persons with Disabilities and/or reviewed for possible Agency for Persons with Disabilities 2 Florida Questionnaire for Situational Information Version changes at least annually at the time of the annual support plan development. The Questionnaire for Situational Information will be re*administered to identify any possible changes in levels of support in the event that an individual experiences major life changes (such as moving from one residential setting to another, major changes in caregivers, or a health change that requires new medications or monitoring, or if the person has experienced major improvements and accomplishments in his/her cognitive or physical condition.)

8 In some cases, the level of support will not change and, in other cases, the level of support will be greater or less, depending on the circumstances. Any concerns or questions regarding this Questionnaire or its use should be directed to the Area APD Program Administrator or to the Agency for Persons with Disabilities in Tallahassee, Florida. Agency for Persons with Disabilities 4030 Esplanade Way, Room 380; Tallahassee, FL 32399 Phone: 850/488*4877 FAX: 850/922*6456 Human Systems and Outcomes, Inc. 2107 Delta Way; Tallahassee, FL 32303*4224 Phone: 850/422*8900 FAX: 850/422*8487 Agency for Persons with Disabilities 3 _____ ___ ___ ___ ___ ___ Florida Questionnaire for Situational Information Version FQSI ADMINISTRATOR Information 1.

9 FQSI Administrator: Print your full name ( , the name of the person administering this Questionnaire ). Print last name first. Last Name First Name 2. Initiation Date (MM/DD/YYYY): Record the date on which the FSIQ is initiated using a month/day/year format. _____ Example: 09/07/2006 3. Administration Date (MM/DD/YYYY): Record the date on which the FSIQ is completed using a month/day/year format. _____ Example: 09/07/2006 4. FQSI Administrator s ID #: Clearly write the five*digit FSIQ administrator number of the person completing this form.

10 Agency for Persons with Disabilities 4 Florida Questionnaire for Situational Information Version 5 Agency for Persons with Disabilities GENERAL Information 1a. Name: First Name M. I. Last Name Area/Region 1b. PIN Number _____ 1c. Medicaid Number ___ ___ ____ of Birth: / / Example 09/12/1962 2a. Mailing Address: Complete if the person s home address is different from his or her mailing address: Person s Complete Mailing Address, Including Apartment # City or Town State Zip Code County of Residence Home Telephone Number 2b.