Skills, gifts, interests, and preferred activities 3 Points 2 points 1 Point 0 Points Score Comments A clear description of the individual’s skills, gifts, interests, and preferred activities. It should be strength based and give the reader an idea of what is most important to the individual. This section should paint a picture of the individual’s skills and interests that assists the reader to “see” the person throughout the rest of the plan’s contents. Score at this level when 3 of the components in this section are covered. Score at this level when 2 of the components in this section are covered. Score at this level when 1 of the components in this section are covered. at this level when 0 of the components in this section are covered. 0 1 2 3 Mark all included in the Community Inclusion Plan: 1. Provides a clear picture of the person’s skills and gifts 2. Provides a clear picture of the person’s likes, interests, and favorite activities 3. Provides a clear picture of who the person is and what is important to them
Does the goal further connect the person to their community and expand the circle of support? The action steps of the plan support this. Score at this level when 3 of the components in this section are covered. at this level when 2 of the components in this section are covered. Score at this level when 1 of the components in this section are covered. at this level when 0 of the components in this section are covered. 0 1 2 3 Mark all included in the Community Inclusion Plan: 1. The individual has opportunities to participate in and contribute to their activity or activities to the best of their ability. 2. The individual is supported to expand their circle of support which includes others who are not paid to provide support. 3. The individual is supported to pursue multiple opportunities for community connections if desired. Action Steps and Supports 7 Points 6 Points 5 Points 4 Points 3 Points 2 Points 1 Point 0 Points Score Comments
The plan identifies what steps and supports are necessary to meet the Community Inclusion goal. It should be clear who is responsible for what to make the plan successful. The action steps should incorporate these characteristics: Specific, Measurable, Attainable, Realistic, and Time-bound (“SMART goals”). Score at this level when all 7of the components in this section are included in the Action Steps. Score at this level when 6 of the components in this section are included in the Action Steps. Score at this level when 5 of the in this section are included in the Action Steps. Score at this level when 4 of the components in this section are included in the Action Steps. Score at this level when 3 of the components in this section are included in the Action Steps. at this level when 2 of the components in this section are included in the Action Steps. at this level when 1 of the components in this section is included in the Action Steps. at this level when 0 of the in this section are included. 0 1 2 3 4 5 6 7 Action Steps include: SMART Goals - 1. Specific 2. Measurable 3. Achievable 4. Relevant 5. Time-bound 6. Identifies the status of the goal (complete, continued, modified, or deleted) 7. Identifies responsible party and/or support needed to ensure the action step is successful
Other accommodations critical to achieving the Community Inclusion goal 2 Points 0 Points Score Comments The plan clearly identifies other accommodations that are necessary to meet the goal. If no accommodations are necessary, this is clearly stated. Score at this level when 1 of the 2 components in this section are covered. Score at this level when 0 of the components in this section are covered. 0 2 If applicable, the plan should clearly identify what the necessary accommodation(s) is/are for the individual critical to achieving the Community Inclusion goal If not applicable, the plan should clearly state “none” and be consistent to support this throughout other sections Respectful and Strengths Language 3 Points 2 Points 1 0 Points Score Comments The plan uses language that is respectful of an individual. Score at this level when the component in this section is covered. at this level when the component in this section is somewhat covered. Score at this level when the component in this section is barely covered. Score at this level when the component in this section is not covered. 0 1 2 3 Mark the one that best describes the Community Inclusion plan: Provides a respectful and strengths based description of the person that is relevant to the plan. The plan’s emphasis is on assets and supports needed to be successful, not the disability and what an individual cannot do. Provides a somewhat respectful and strengths based description of the person that is relevant to the plan. Some of the plan’s emphasis is on assets and supports needed to be successful, not the disability and what an individual cannot do.