FUNCTIONAL COMMUNITY ASSESSMENT CATEGORIES
Use these Functional Community Assessment categories with examples provided to identify areas that the individual generally requires substantial physical assistance and/or constant supervision or moderate frequent support/assistance. Complete this when a new client starts (Intake) and every year thereafter during the client's 3rd Quarter, before completing the Person-Centered Planning. From your observations and discussions with the individual and circle of support, determine which areas the individual may want to work on for the upcoming year.
SAFETY/EMERGENCIES
Doors/windows/latches – locks when home

Uses peephole/asks who before opens door

Night - closes drapes, turns on outside lights

Brings in mail/papers/Arranges if away

Can handle prank/obscene phone calls

Uses sharp items (knives, scissors) safely	Smoke detector - tests batteries, resets

Fire extinguisher - knows how to use

Evacuate - knows how and when to evacuate home

Knows when to contact emergency numbers (911, police, fire, ambulance)

Maintains/uses first aid kit properly	Uses household appliances and outlets safely

Knows emergency procedures (injury, accident, illness)

Knows emergency procedures

Dials phone; looks up numbers in phonebook

Stores flammable materials properly
HEALTH/SEXUALITY	CONSUMER SKILLS
Cleans and bandages cuts

Makes, keeps, and cancels (in advance) medical/ dental appointments

Wears medical alert, if appropriate

Fills prescriptions

Knows rights if arrested

Deals with life stressors appropriately	Takes prescriptions and other medications according to instructions

Understands and practices safe, consensual sex

Differentiates between casual /intimate relationship

Understands sexually transmitted diseases (symptoms, prevention)

Understands consensual/non-consensual sex	Uses a vending machine, post office, coupons

Knows clothing and shoe sizes

Able to select good buys

Returns items for refund/exchange

Makes shopping list/purchases items from list

Pays for purchases with cash/check/credit card

Orders from menu; sends `bad' food back
HOUSEHOLD MANAGEMENT	MONEY MANAGEMENT
Dusts furniture, cleans/vacuums under cushions and furniture

Sweeps, mops, and/or vacuums floors

Cleans microwave/oven

Cleans/defrosts refrigerator

Washes trash/garbage cans

Makes bed, changes linens regularly

Cleans bathroom (tile, fixtures, tub, sink)	Keeps cupboards, drawers, closets organized

Regularly reviews/discards papers, coupons

Keeps home free of fleas, roaches, rodents

Washes, dries, and stores dishes

Wipes table tops and counters

Takes out trash

Maintains outside of home (mow, rake, garden)

Does minor home repairs/contacts repair persons	Recognizes coins, paper bills and value

Budgets income

Plans for purchases

Writes checks Mails/delivers bills on time

Identifies amount due on bills

Adjusts budget based on changes in income/ expenses

Enters checks in register; balances; reconciles
MEAL PREPARATION	SELF CARE/HYGIENE	CLOTHING CARE
Plans menus; Makes shopping list

Stores food properly

Uses a microwave

Makes simple food (cereal, sandwich, salad)

Follows multi-step recipe to prepare food

Follows nutritious diet

Uses stovetop; Uses oven

Uses small kitchen appliances	Bathes/showers daily

Uses deodorant

Shaves

Cares for menstrual cycle

Brushes teeth at least daily; uses mouthwash

Keeps nails clean and trimmed

Keeps hair combed, trimmed, styled

Washes hands (after tolieting, before handling food)	Uses washing machine/dryer; measures soap

Soaks stained clothes

Uses an iron

Sorts clothes before washing

Sews buttons and makes minor repairs

Polishes shoes/washes sneakers

Changes into clean, unwrinkled clothes daily

Wears clothes appropriate for the weather
COMMUNICATION	COMMUNITY MOBILITY	INTERPERSONAL RELATIONSHIPS
Speaks

Reads (mail, magazines, books, etc)

Writes

Makes and returns phonecalls

Tells time accurately

Writes signature

Uses a calendar

Writes letters/sends cards to friends/ family

Rides bike/follows safety rules	Uses public transportation or taxi

Arranges/provides own transportation

Crosses street at corners/looks both ways

Carries emergency info (ID, meds, allergies, contact names and numbers)

Walks to neighborhood sites (church, store, library) without getting lost

Stops, looks, and listens

Asks for directions	Participates in spiritual, civic, community, or political groups

Active in neighborhood assoc/groups

Volunteers

Participates in hobby clubs/sports team

Associates appropriately with neighbors/ acquaintances

Attends social functions (parties, weddings, dances)

Maintains friendships; Reciprocates invitations
LEISURE TIME/ACTIVITIES/INTERACTIONS
Participation or use:

Audiovisual equipment (tv, vcr, cd, radio)

Books, magazines, papers, movies, videos

Exercises (walk, jog, aerobics, yoga, swim, karate, gym)

Sports (fishing, skiing, driving, boating)

Library/community centers

Visits community centers for social events

Attends adult education/other classes	Goes to movies, shows, plays, concerts

Arts and crafts

Gardening/cares for house plants; Cares for pets

Decorates for seasons/holidays

Plays musical instrument/sings

Cultural events (plays, lectures, exhibits, concerts)

Bars/clubs

Attends spiritual services/related activities

Goes for walks, bike rides, skates, hikes; takes trips	Does volunteer work

Engages in friendly conversation

Goes shopping

Telephones friends; visits friends, family

Goes out for meals

Attends club/organization meetings

Participates in sports/attends sporting events

Attends recreational, health clubs

Registers to vote; votes
POSITIVE CHARACTERISTICS	LIMITING FACTORS	ACCESSING RESOURCES
Outgoing nature; Sense of humor

Communication skills, grooming, appearance

Social behaviors and manners

Caring/concern for others; warmth; sincerity

Popular interests/hobbies	Unusual behaviors, speech patterns, or mannerisms or ambulating limitations

Communication skills (poor or none)

Eating skills (limited or different)

Special medical problems	Applies for/deposits benefits (SS, FS, other)

Reports changes in income to SS Admin

Uses EBT card for FS

Reports un-received checks/FS/ ID cards

Applies for, renews, replaces ID cards