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Draft Revised 8/25/05
INTRUM RISK ASSESSMENT SCREENING TOOL
(Questions to be incorporated in SIS Assessment tool when implemented)
Name:Date:
Client ID:Age:
Individual Completing this Form:
** Several items have been cross-walked with the AAMR Supports Intensity Scale (SIS).
Other items will be added as additional questions to the SIS assessment.
Assessments questions to address measuring the level of risk for each checked risk factors:
- Current treatment and effectiveness
- Additional supports needed
- Anticipated future needs
Please rate the issues that are risk factors for this individual in the following categories.
(Indicate the following for each item: 0= No support needed, 1= Some support needed,
2 = Extensive support needed.)
A. Category I
Risks to Personal Safety: Caretaker and Environmental Risk
A caretaker, relative, house mate, friend or any person who has a history of, or is determined to be capable of the following actions or a situation or environment in which these could occur.
1.__ Incapacitated Caretaker Or Loss Of Primary Caretaker/ Natural Supports
2.__Housing Related to Family Dwelling
3.__History Of Neglect and/or Abuse
4.__Refusal of services by caretaker
5.__Criminal Activity By Caretaker
6.__Possible Sexual Exploitation (Sec II-3: Protecting self from exploitation)
7.__Financial Exploitation (Sec II-3: Protecting self from exploitation)
8.__Social Isolation (Sec I-F-3: Socializing outside the household)
B. Category II
Individual Behavioral Risks
(Risk factors are directly related to an individual's behavior not the behavior of others)
The individual's behaviors are dangerous to themselves or threaten public safety.
9.__Housing related or homeless (due to individual's behavior)
10._Pregnancy and parenting issues
11._Criminal Justice Involvement not related to sexual activity
12._Refusal of critical services or treatment and medical
13._Unsanitary / inappropriate living conditions (Sec A-5: Housekeeping and cleaning)
14._Financial/Money Management issues (Sec 2-2: Managing money and personal finances)
Loaning money/indebtedness/financial exploitation by others/excessive gambling
15._Substance Abuse (Sec 3-B-11: Prevention of substance abuse)
16._Significant Self-Injurious Behavior (Sec 3-B-4: Prevention of self-injury)
17._History of Aggression (Sec 3-B-1: Prevention of assaults or injuries to others)
Threats of violence or repeated destruction of personal or private property
18._History of fire setting or fascination with fire (Sec 3-B-2: Prevention of property destruction)
19._Issues With Personal Safety (Sec 1-E-2 Avoiding health and safety hazards / Sec 2-3: Protecting self from exploitation
Frequent victimization, uses poor judgment in unsafe situations
20._ Reported History of Problematic Sexual Behaviors (including criminal) (Sec 3-B-7: Prevention of sexual aggression and 8: Prevention of non aggressive but inappropriate behaviors)
21._Complex post hospital care needs psychiatric issue ( Sec 3-12: Maintenance of mental health treatments)
22._Sufficient change in mental health and behavioral conditions / History of Mental Health conditions (Sec 3-12/ 13: Prevention of other serious behavior problem(s)
C. Category III
Health Risks
Individuals who have a medical condition(s) and are in need of significant medical safeguards, which may
include, but not be exclusive to, the following:
23._Multiple unplanned hospitalizations
24._Complex post hospital care needs not psychiatric issues
25._Significant negative change in medical status
26._Chronic eating disorders and /or including obesity
27._Swallowing /choking /aspiration disorders
28._Chronic medical problems (e.g., diabetes, conjestive heart failure, chronic obstructive pulmonary disorder)
29._Complex medication issues due to multiple medication and side effects
30._Medication related issues due to taking medication (Sec E-1: Taking medications)
31._Infectious disease processes including STD’s, Methicillin Resistant Staphylococcus Aureus (MRSA), Hepatitis, Chronic cellulites (Sec 3-10: Protection from infectious disease due to immune system impairment)
List any other issues that may be risk factors for this individual:
32.
Risk Assessment questions to be addressed in the individual’s Person Center Plan or in a separate Risk Plan for each identified area of risk.
- What is the team’s evaluation of the risk? Have the risk/ benefits been weighed?
- What can be done differently to prevent these safety risks? What strengths/ assets does the individual have towards prevention?
- Who can help with prevention measures?
- What supports would minimize the risks?
- Who can provide these supports?