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CSSP form for IHS programs

Please fill out the form according to the person’s CSSP addendum. We will use the information to create the quiz on Dayforce.

CSSP for IHS

Your Name

Unique ID of your person

Does this person need support with hearing or vision?

Yes

Does this person have a history of seizures?

Yes

What allergies does the person have? Make a list separated by commas. For example: Pollen, Eggs (if none put none)

Does this person ambulate independently?

Yes

No-- the person needs at least some support while walking or in the wheelchair

Does the person have any risks in regards to sexual abuse? (Select all that apply)

This person is NOT at risk of sexual abuse.

Inability to be assertive.

Lack of understanding or sexuality.

Likely to seek or cooperate in an abusive situation.

Displays sexual behavior

Does the person have risks in regards to physical abuse? (select all that apply)

The person is NOT at risk for physical abuse.

Inability to deal with verbally/physically aggressive persons.

Inability to identify potentially dangerous situations.

“Victim” history exists.

Verbally/physically abusive to others.

Lack of community orientation skills.

Inappropriate interactions with others.

Is this person susceptible to self-abuse? (Select all that apply)

The person is NOT at risk of self-abuse.

Eats non-edible substances.

Unsafe conduct in a vehicle.

Dresses inappropriately

Elopement

Refuses to eat.

Chooses not to take medications.

Lack of self-preservation skills (ignores personal safety).

Inability to care for self-help needs.

Engages in self-injurious behaviors.

Alcohol, tobacco, drug use.

Is this person at risk of financial exploitation?

Yes

Does this person have a history of inaccurate reporting?

Yes

Is this person their own guardian?

Yes

Can the person use a public restroom alone?

Can staff leave a person alone while they go into a public restroom?

Can staff leave a person alone in the car?

CSSP form for IHS programs

Orion Associates

820 Lilac Drive N.

Golden Valley, MN 55422