IM4Q Visit Signs of Quality and Considerations
Cycle 12 ~ FY 10-11
PERSON’S NAME:
___________________________
DATE OF EDE INTERVIEW:
CNSR ID#:
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VFE ID #:
______________
____/____/________
RESIDENTIAL PROVIDER (IF ANY): ___________________________
DAY/WORK PROVIDER (IF ANY): ___________________________
SUPPORTS COORDINATION ORGANIZATION:
_____________________
LOCATION OF INTERVIEW: ______________________________________________________________
VOLUNTEER
MONITOR: _______________________ DATA COLLECTOR(S): _______________________________
Please note any information not on the pre-survey that you uncovered during the interview process, such
as family contact information, change in Supports Coordinator (list name and contact # when possible),
etc. in the space provided below.
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IM4Q Consideration Themes
1. Adaptive Equipment:

Any personal (not building related, e.g., a ramp) adaptive equipment
an individual requires and that touches/is used by his/her body such
as a wheel chair; special utensils for eating; leg/arm braces.

Any funds necessary to obtain the adaptive equipment
2. Communication Needs/Device/Services:

Person may benefit from a communication device

Person has a non functioning communication device that needs repair

Person’s staff/family does not know how to use the device

Person only gets to use the device in a particular setting Staff could
benefit from training in using communication strategies/devices

Any funds required to address this area
3. Community Presence and Participation:
This includes any event that takes place in the community (not in a person’s
home/place of residence/at work/school).

Civic/political groups (e.g., Neighborhood Watch, Political Party)

Social/racial/ethnic/fraternal/sorority/other groups (Knights of Col.)

Athletic/recreational/sporting event (e.g., attending a sporting event)

Joining athletic/recreational/sporting groups (e.g., softball league)
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Cultural/artistic (attending a play/symphony, an art/dance class)
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Associational groups (e.g., Rotary, National Rifle Association)
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Hobbyist (e.g., Stamp Collecting)
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Clubs, various organizations that meet in the community

Outings that are in the community (e.g. going shopping, to the mall)
4. Health/Well Being:

Person may request an appointment to see a physician, therapist,
counselor, dietician, nutritionist, and/or exercise specialist, etc.

As a monitor you perceive some medical, psychological, health (e.g.,
weight/dietary/vision, hearing, smoking, alcoholic drinking other)
concern

Living Will

Any funds necessary to address this area
5. Personal Rights, Competence Enhancement and Growth:

Learning about and practicing one’s citizenship rights such as voting

Having an ID (form of identification)

Getting a pet

Having a key(s)/a means to enter one’s residence/room

Attending a meeting of/joining a self advocacy group
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Privacy issues
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Learning a skill (e.g., using a computer; learning to drive); craft (e.g.,
needlepoint, scrap booking); hobby (e.g., collecting sea shells; coins)

Growing in independence, choice, control, decision making, and
autonomy

Taking an educational/learning/training course to increase one’s
competence (e.g., reading; budgeting; cooking; home cleaning)

Athletic/recreational/sport skills (e.g., fishing; volleyball; baseball)

Choosing clothing; cosmetics; hairstyle, etc./personal grooming

Finances for any of the above
6. Relationships/Friendships:
This includes: Family, friend, roommate, neighbor, social/romantic (boygirl/friend) and other non-staff/non-paid relationships. These relationships and
friendships could be at the person’s place of residence, work, school, worship,
and play.

Person indicates the need/desire to re-establish, renew, establish, seek
out a relationship/friendship with any of the above listed groups of
people

Person indicates an interest in or assistance with a boy/girl friend
relationship

Considerations concerning sexuality would fall under this theme

There is a lack of, inconsistent, inappropriate relationship/friendship
with any of the above parties, poor communication
7. Residential/Living Situation Personal Change:

Change of roommate

Request for no roommate

Request to live elsewhere in same type of setting

Request to live elsewhere in a different type of setting (e.g., from a
group home to one’s own apartment; family home to home of one’s
own apartment; out of nursing home to shared apartment)

Request for respite are in this category

Any staff supports needed for residential living

Any financial requests for residential services
8. Residential – Building Adaptations/Modifications:

Need for structural adaptation or modification in/outside of residence
(e.g., ramp, accessible bathroom/room, raised/lowered counter tops,
tilted mirrors, push button locks, adapted door knobs)

Need for any repairs/modifications in or outside of the home
(consider if a Major Concern)

Need for change of or furnishings in one’s residence/living situation

Are the any maintenance needs inside and/or outside the
residence/living situation (e.g., cleanliness; leaks; limbs hanging on
the roof)

Any necessary funding
9. Safety:

Person indicates some concern with their safety (e.g., physical,
emotional, psychological/mental) that is from outside them self,
brought on by someone else

As a monitor you witness or sense a safety issue for the person in the
above areas

Are there safety issues in and or outside of the person’s
residence/living situation (e.g., unsafe neighborhood with drug
dealers; broken sidewalks; loose railing) that goes beyond just a
cosmetic repair and definitely jeopardizes a person’s physical safety?
Note: Safety considerations may be Major Concerns
10. Service System:

Supports Coordinator issues

Staff ratio/turnover/training issues

Request for services from ODP/County/AE requiring funding other
then vocational/day, residential, transportation which are under
those categories

Requests for information on any aspect of ODP/County/AE services
(e.g., person centered planning; self determination; waiver funding;
services available; transition planning). Only information is being
requested at this point in time, not actual service.

Legal, financial planning

Lack of, inconsistent, poor or inappropriate communication between a
family member and/or the person served with someone in the service
system (e.g., supports coordinator; county/AE staff; service provider;
residential/work staff)
11. Spiritual Life:

Request to attend a formal religious denomination of ones choice

Request for more spiritual opportunities in one’s life (e.g., to meditate,
pray)

Request to join/attend a faith community event/activity (e.g. choir,
meeting, social)
12. Transportation:

Request for regular transportation to an event/activity the person
wants to attend

Request for accessible transportation to an event/activity person
wants to attend

Transportation is available and person needs finances (system/other)
to use it

Transportation exists and routes are limited
13. Work/Employment/Meaningful and Purposeful Activity:

New job request

Job change request

Volunteering request

Evaluation of skills for work

Work/vocational support (e.g., a job coach)

Retirement to meaningful/purposeful activity

Any financial requests for work
14. Miscellaneous:
Please make an effort to place considerations under one of the 13 above
categories. If you have a consideration that does not fit above then use the
miscellaneous theme category as a last resort.
If you can’t decide on a category, the Monitor will ask for assistance with that
particular consideration at the weekly Monitors’ meeting.
Please do your best to give as much detail as possible (so that we can
accurately interpret your consideration and pass it on to the Supports
Coordinator). You are encouraged to attach a sheet of paper if you need more
room.
CONSIDERATIONS
CONSIDERATION THEME (record # here):
SOURCE:
Person
Staff Residential
Staff Day/Work
Family/Friend/Guardian
IM4Q Team
DETAILS (please give as much information as possible):__________________________________________
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CONSIDERATION THEME (record # here):
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SOURCE:
Person
Staff Residential
Staff Day/Work
Family/Friend/Guardian
IM4Q Team
DETAILS (please give as much information as possible): __________________________________________
_____________________________________________________________________________________
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C
ONSIDERATION THEME (record # here):
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SOURCE:
Person
Staff Residential
Staff Day/Work
Family/Friend/Guardian
IM4Q Team
DETAILS (please give as much information as possible):__________________________________________
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CONSIDERATION THEME (record # here):
________
SOURCE:
Person
Staff Residential
Staff Day/Work
Family/Friend/Guardian
IM4Q Team
DETAILS (please give as much information as possible):__________________________________________
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CONSIDERATION THEME (record # here):
________
SOURCE:
Person
Staff Residential
Staff Day/Work
Family/Friend/Guardian
IM4Q Team
DETAILS (please give as much information as possible):__________________________________________
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CONSIDERATION THEME (record # here):
SOURCE:
Person
Staff Residential
Staff Day/Work
Family/Friend/Guardian
IM4Q Team
DETAILS (please give as much information as possible):__________________________________________
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CONSIDERATION THEME (record # here):
________
SOURCE:
Person
Staff Residential
Staff Day/Work
Family/Friend/Guardian
IM4Q Team
DETAILS (please give as much information as possible): __________________________________________
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C
ONSIDERATION THEME (record # here):
________
SOURCE:
Person
Staff Residential
Staff Day/Work
Family/Friend/Guardian
IM4Q Team
DETAILS (please give as much information as possible):__________________________________________
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CONSIDERATION THEME (record # here):
________
SOURCE:
Person
Staff Residential
Staff Day/Work
Family/Friend/Guardian
IM4Q Team
DETAILS (please give as much information as possible):__________________________________________
_____________________________________________________________________________________
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CONSIDERATION THEME (record # here):
________
SOURCE:
Person
Staff Residential
Staff Day/Work
Family/Friend/Guardian
IM4Q Team
DETAILS (please give as much information as possible):__________________________________________
_____________________________________________________________________________________
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SIGNS OF QUALITY
Check the positive elements that are present in the individual’s life & write a brief description in the theme’s space below. Do not limit
your notes to the check box categories. When in doubt, write general notes on the “Notes” page that follows and then categorize post-visit.
1. Adaptive Equipment
 Has what is needed
 Well-maintained
 Correct size
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2. Communication Needs/Device/Services __________________________________________________________
 Communication needs met
_____________ ____________________________________________________
 Learning communication skills
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 Staff/family can use device/signing
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 Communication device well-maintained _________________________________________________________________
3. Community Presence & Participation ____________________________________________________________
 Belongs to athletic group
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 Recreational day trips
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 Meaningful activities
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 Club member  Cultural outings
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4. Health /Well Being
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 Has regular visits with doctor
 Exercises
 Health needs met
5. Personal Rights, Competence Enhancement & Growth
 Votes
 Has travel training
_________________________________________________________________
 Has ID; key  Has a hobby
_________________________________________________________________
 Has privacy  Learning a new skill
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 Has a pet
 Continuing education _________________________________________________________________
 Makes choices  Is a self-advocate
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6. Relationships/Friendships
 Has meaningful relationships
 Has friends
 Has family involvement
 Compatible with housemate
7. Residential/Living Situation
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 Chose to live here
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 Ample space
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 Convenient to shopping, recreation, etc. _________________________________________________________________
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8. Resid-Bldg Adaptations/ Modifications _____________________________________________________________
 Home meets accessibility needs _______________________________________________________________________
 Interior in good condition
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 All needed modifications made _______________________________________________________________________
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9. Safety
 Safe neighborhood
 Has safety skills
 Feels safe outside of home
 Feels safe in home
10. Service System
 Good relationship with SC
 Consistent staffing
 Knowledgeable staff
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11. Spiritual Life
 Chooses place of worship
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 Has role at above (choir, usher, etc.) ____________________________________________________________________________
 Involved in other religious activities _____________________________________________________________________________
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12. Transportation
 Has dependable transportation
 Available when needed/wanted
 Available weekends
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13.Work/Employment/Meaningful Activity ___________________________________________________________
 Has a job
 Recent employment eval. _________________________________________________________________
 Chose to retire  Has job coach
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 Volunteers
 Day program/workshop _______________________________________________________________________
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Miscellaneous
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Notes
Take general notes here and/or record any additional information regarding the interview in the space below. If the Data
Collector is using a notebook or loose-leaf paper to record notes, you may also attach those additional papers to this booklet.
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Monitors’ Phone Log:
Record all attempts to contact the individual, their contact, or family below:
EDE scheduling:
Date
Time
Contact
Outcome (left message, no answer, scheduled appt.,
etc.)
EDE confirmation:
Date
Time
Contact
Outcome (left message, no answer, scheduled appt.,
etc.)
FFG attempt #1
Date
Time
Contact
Outcome (left message, no answer, scheduled appt.,
etc.)
FFG attempt #2
Date
Time
Contact
Outcome (left message, no answer, scheduled appt.,
etc.)
FFG attempt #3
Date
Time
Contact
Outcome (left message, no answer, scheduled appt.,
etc.)
Please make every effort to complete the FFG survey yourself, as the family often has questions
regarding their loved one and the visit itself that you are best equipped to answer (having seen the
individual). After three unsuccessful attempts to contact the family member, please check the
“mail FFG survey” box below. Thank you for your hard work and dedication to IM4Q!
MAIL FFG
NO FAMILY
DO NOT CONTACT (per individual’s request)