DSF ANNUAL STAFF RATIO DETERMINATION WORKSHEET
Service Recipient Name: _______________________________ Date: _____________________
Level of assistance from staff to successfully complete the following activities:
Independent
Minimal Verbal
Prompts
Frequent Verbal
Prompts
Minimal Physical
Assistance
Communicating
N/A
1
2
3
Constant
Hand-over-Hand
Assistance
4
Basic Needs
N/A
1
2
3
4
5
Eating
N/A
1
2
3
4
5
Toileting
N/A
1
2
3
4
5
Ambulating
Taking appropriate action
for self-preservation under
emergency conditions
N/A
1
2
3
4
5
N/A
1
2
N/A
4
5 (not capable)
Total Care
& Monitoring
5
Ratio of 1:2 Five of the following must be true:
Code 4 or 5 for Communicating Basic Needs
Code 4 or 5 for Ambulating
Code 4 or 5 for Toileting
Code 4 or 5 for Eating
Code 4 or 5 for Taking appropriate action for self-preservation under emergency conditions
OR:
the person engages in conduct that poses an imminent risk of physical harm to self or others at a
documented level of frequency, intensity, or duration requiring frequent daily ongoing intervention and
monitoring as established in the person's coordinated service and support plan or coordinated service and support
plan addendum.
Ratio of 1:3 Four of the following must be true:
Code 4 or 5 for Communicating Basic Needs
Code 4 or 5 for Ambulating
Code 4 or 5 for Toileting
Code 4 or 5 for Eating
Code 4 or 5 for Taking appropriate action for self-preservation under emergency conditions
OR:
the person engages in conduct that poses an imminent risk of physical harm to self or others at a
documented level of frequency, intensity, or duration requiring frequent daily ongoing intervention and
monitoring as established in the person's coordinated service and support plan or coordinated service and support
plan addendum.
Ratio of 1:4 Three of the following must be true:
Code 4 or 5 for Communicating Basic Needs
Code 4 or 5 for Ambulating
Code 4 or 5 for Toileting
Code 4 or 5 for Eating
Code 4 or 5 for Taking appropriate action for self-preservation under emergency conditions
OR:
the person engages in conduct that poses an imminent risk of physical harm to self or others at a
documented level of frequency, intensity, or duration requiring frequent daily ongoing intervention and
monitoring as established in the person's coordinated service and support plan or coordinated service and support
plan addendum.
Revised 6/14
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Ratio of 1:5 Four of the following must be true:
Code 1 – 3 for Communicating Basic Needs
Code 1 – 3 for Eating
Code 1 – 3 for Toileting
Code 1 – 3 for Ambulating
Code 1 or 2 for Taking appropriate action for self-preservation under emergency conditions
**If Code 4 or 5 for Taking appropriate action for self-preservation under emergency conditions in addition
to four of the above criteria, the individual is a 1:4.
Ratio of 1:6 Three of the following must be true:
Code 1 – 3 for Communicating Basic Needs
Code 1 – 3 for Eating
Code 1 – 3 for Toileting
Code 1 – 3 for Ambulating
Code 1 or 2 for Taking appropriate action for self-preservation under emergency conditions
**If Code 4 or 5 for Taking appropriate action for self-preservation under emergency conditions in addition
to four of the above criteria, the individual is a 1:4.
Ratio of 1:7 Two of the following must be true:
Code 1 – 3 for Communicating Basic Needs
Code 1 – 3 for Eating
Code 1 – 3 for Toileting
Code 1 – 3 for Ambulating
Code 1 or 2 for Taking appropriate action for self-preservation under emergency conditions
**If Code 4 or 5 for Taking appropriate action for self-preservation under emergency conditions in addition
to four of the above criteria, the individual is a 1:4.
Ratio of 1:8 One of the following must be true:
Code 1 – 3 for Communicating Basic Needs
Code 1 – 3 for Eating
Code 1 – 3 for Toileting
Code 1 – 3 for Ambulating
Code 1 or 2 for Taking appropriate action for self-preservation under emergency conditions
**If Code 4 or 5 for Taking appropriate action for self-preservation under emergency conditions in addition
to four of the above criteria, the individual is a 1:4.
Describe the situations or rationale in which a ratio better than that identified would be
necessary (e.g., the health and safety needs of the person receiving services cannot be met by the number of staff
members determined by this form, the person's conduct frequently presents an imminent risk of physical harm to
self or others (per MN Statute 245D.31), employment, community-based experiences, CSSP/CSSPA/SMA/IAPP
requirements, medical issues, significant and frequent 1:1 time in restroom, social needs, etc.):
________________________________________________________
Staff Member Completing Form
Revised 6/14
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