[nfbmi-talk] Independent Living Manual

Larry Posont president.nfb.mi at gmail.com
Wed Dec 21 15:32:32 UTC 2011


20812 Ann Arbor Trail
Dearborn Heights, MI 48127

December 21, 2011

Dear everyone:
Here is the Independent Living Manual that I requested as a
Commissioner from Mr. Cannon. I believe that many of you will be
interested in this information.

Sincerely,
Larry Posont, Commission for the Blind Board Member
 The primary goal of The Commission for the Blind is the
gainful employment of Michigan's blind citizens. This is my primary
goal as a Commissioner.

(313) 271-3058
Email: president.nfb.mi at gmail.com
IL Procedure Manual

INDEPENDENT LIVING (IL) PROGRAM INTRODUCTION

Within the IL Program, clients are defined as either Part B or Older
Blind (OB).  The determination of a client as Part B or Older Blind is
done by the VRT.  The percentage of clients who are in either group is
based on the amount of money available for Older Blind or Part B
services.

Outreach activities are an integral part of the IL Program.  These
activities are designed to educate the general public including other
professionals about blindness, the services available from the IL
Program, blindness prevention, adaptive equipment, skills of blindness
for increased independence, and the availability of professional
brochures and pamphlets about various eye conditions.

SERVICES

The cost of services may be met through the resources of the MCB IL
Program or other individuals and agencies (comparable benefits). Based
on a documented need, any of the following non-diagnostic services may
be available to an IL client:

1. Peer counseling/support and guidance
2. Training and training materials
3. Maintenance limited to attending Mini Adjustment Program and/or MCB
Training Center (MCBTC)
4. Transportation (not on a regular basis)
5. Services to members of the client's family (limited to
Counseling/support and Guidance in basic skills of blindness)
6. Interpreter services as needed by MCB to provide services to the client
7. Information and referral services
8. Other goods and services necessary to achieve the IL objectives.

COST

Providing equipment and devices is a luxury that should be used with
discretion.  The true value of the IL Program is the information and
training that the VRT can provide.  Do not construe that the ability
to provide equipment is a chance for a client to go “shopping”.  A
global budget outlining caseload expenditures will be established by
the Director of Client Services at the beginning of each fiscal year,
and this information will be forwarded to the VRT.  Resources and
services available through programs other than MCB’s IL Program should
be shared with the client as much as possible.  Some examples of these
kinds of services are the National Library Services\ Talking Book
Program, Radio Reading Services such as the Detroit Radio Information
Service (DRIS) and the WKAR Radio Reading Service (central Michigan),
the local Center for Independent Living (CIL), a local support group,
Veterans Affairs (VA), the VA Visually Impaired Services Outpatient
Rehabilitation (VISOR), etc.

MCB does not require a financial needs test to determine client's
eligibility for the cost of services.  In the spirit of independent
living, clients are encouraged to participate in the cost of their
program to the extent that they are able. This is a good practice, as
it allows the agency to provide services to more clients and may also
increase the chance for success, as the client by his/her financial
participation, is demonstrating an interest in achieving the IL
objectives. The agency cannot deny appropriate services to clients who
refuse to participate financially in the cost of their program.

ELIGIBILITY

In order to be eligible for Michigan Commission for the Blind
rehabilitation/independent living services:
A. An individual must have a visual impairment as defined by Public Act 260.
DEFINITION OF LEGAL BLINDNESS: THE INDIVIDUAL’S VISUAL ACUITY WITH
BEST CORRECTION MUST BE 20/200 OR WORSE IN THE BETTER EYE OR HIS/HER
VISUAL FIELDS MUST SUBTEND AN ANGLE OF LESS THAN 20 DEGREES IN EACH
EYE.
or
THE INDIVIDUAL MUST HAVE A VISUAL ACUITY WITH BEST CORRECTION 20/100
OR WORSE IN THE BETTER EYE WITH A PROGNOSIS OF RAPID DETERIORATION.
B. The impairment must constitute or result in a substantial
impediment to employment and/or independent living for the individual.
C. It is presumed that the individual can benefit in terms of an
employment and/or independent living outcome.

Individuals who are 55 years of age and older who meet the requirement
of a severe impediment to employment but who are not capable of
competitive employment and who are not capable of performing
substantial work in the four core areas such as Kitchen Skills, Travel
Skills, Home Management, and Communication Skills shall be referred to
the Michigan Commission for the Blind Independent Living Program.

EYE EXAMINATION REPORT

Securing an eye examination report for an individual applying for
services is the first step in the determination of eligibility. This
is the only report required in the determination of eligibility.  All
ophthalmological or optometric reports used in establishing
eligibility for service must be signed by a licensed ophthalmologist
or optometrist.

The VRT should check to be sure the report contains:
1.	Diagnosis
2.	Prognosis of condition
3.	Best corrected visual acuity and/or
documented field loss of 20 degrees or less

If the report is incomplete, the VRT should obtain the missing
information either by phone or in writing from the entity completing
the form.

SERVICES TO PEOPLE WHO ARE EMPLOYED

The IL Program is designed to meet the needs of people whose potential
for employment is extremely limited. This targeted population consists
of people who are blind or have low vision who are age 55 or older.
If an IL client expresses interest in employment, the VR Counselor
should be contacted to pursue this interest.  The case may remain open
in IL until the IL services are completed.

SERVICES TO AGENCY EMPLOYEES AND/OR THEIR FAMILIES

Commission for the Blind staff and their relatives are eligible to
receive agency IL services if they meet the eligibility criteria. As
with all other clients, services may not be provided if they are
available through the resources of other agencies and/or individuals
(comparable benefits).  When the case file is closed, it must be
forwarded to central office for storage immediately upon closure. The
case file material may not be included in the employee's personnel
file.

IL services to relatives of employees will be considered as for any
other citizen who has a disability. The case of a relative of a MCB
employee should not be assigned to the staff person to whom the
individual is related.

NURSING HOME RESIDENTS

Individuals who have potential for increased independence or are
targeted for exiting a nursing home may receive services.  VRT should
work with the nursing home staff regarding exit dates and strategies.

REFERRALS

A referral for IL services may be made by the person with a vision
impairment or blindness, by any individual who is in a position to
speak for the person, or by public or private agencies which are
interested in the person. To establish a referral, the VRT needs the
following information regarding the person:
1. Name
2. Address, including zip code
3. Birth date or age
4. Referral source
5. Social Security Number or alternative

There should be some indication that the client is legally blind. If
possible, in the case of a medical referral, request a letter from the
referring physician detailing the eye condition, diagnosis, prognosis,
and visual acuity. Such a letter may be acceptable as the eye report
for the case record.

NON-DISCRIMINATION STATEMENT

All services are provided without regard to race religion, gender,
age, color, marital status, national origin, impairment, or political
beliefs.

ASSIGNING AND CONTACTING REFERRALS

Referrals are assigned to a VRT based on county of residence.  The VRT
should contact the client within three weeks of receiving the referral
to explain IL services.

RESIDENCY REQUIREMENT

There are no residence requirements for referrals. No person shall be
excluded as a referral on the basis of state residence. In the event
of an out-of-state referral, the VRT should inform the prospective
client that IL services may be available in the particular state where
he or she resides. If the prospective client still wishes to receive
IL services from the Michigan Commission for the Blind, the client is
to be treated as a referral and expected to come to Michigan for
services. VRT should inquire about previous residence and determine if
the client is presently a client of another IL agency.

APPLICATION FOR SERVICES

If the client is interested in obtaining IL services, he/she will be
expected to sign an appropriate application.

SECURING SURVEY INFORMATION

The intake interview is conducted by the VRT.  The focus of the
initial interview should be for the prospective client to describe IL
needs in his/her own terms. During this first interview the VRT may
obtain historical information regarding the prospective client’s
impairment as it relates to his or her disability. All clients are
entitled to participate in the diagnostic process to determine their
eligibility for MCB services.

Interview information regarding the disability, previous examinations,
and treatment will enable the VRT to decide whether reports or
summaries should be requested from doctors, clinics, or hospitals. If
the prospective client has had a recent eye or medical examination the
VRT should, at the time of the intake interview, have the prospective
client sign the Release of Information form.  In those instances of
long-standing total blindness (e.g. enucleation), no eye report is
required.  VRT must document in the case record why no eye report is
present.  This documentation should also be filed in the paper file.

The VRT observation of the prospective client's behavior may be
important in determining IL needs. Observation should be documented
and may be used in planning with the client.  During the initial
interview, the VRT should record the name and telephone number for an
alternate contact person (not living with the client). This person may
be helpful in contacting a client if he or she moves without notifying
the agency.

When completing the Demographic Form and IL Open forms, it is
important that information be reported accurately. It is also
important to include detailed driving instructions. Do not hesitate to
include any information that will make locating the client easier,
e.g., color and type of house, nearby businesses, natural landmarks,
etc.

ASSESSMENT OF IL NEEDS

Training goals will be based on the assessment and will be reviewed
with the client at the completion of the assessment interview.
Training goals will be consistent with the client’s informed choice
and recorded in the case notes (IL) or in the IL Plan.


IL PLAN and PLAN WAIVER (IL only)

Most consumers will have more than one goal and these goals will
become their independent living plan.  If the IL client does not wish
to have a plan written, s/he should sign a Plan Waiver which is filed
in the paper file.  Even in those cases, at least one goal must be
created in order to satisfy federal requirements for the definition of
a Consumer Service Record (ILOB).

DIAGNOSIS AND EVALUATION

All individuals are entitled to a preliminary assessment. The purpose
of this assessment is to identify the individual’s needs for services
independent living services.  Factors other than vision loss may
impact the client’s ability to achieve increased independence.  In
such cases, the VRT should document these observations.  Information
and referral should be considered significant services.  Limited VRT
services may be considered in such areas as; a client who receives
Talking Book assistance is taught a way to tell time and is provided
with a system to write a letter has received significant services.

REPORTS

CLIENT INFORMATION RELEASE AUTHORIZATION

If the VRT wishes to obtain information from the records of an agency
or individual, it is necessary to have the client authorize the
release of this information by signing a Release of Information form.
In all cases, the information on the release form must be completed
before the client is asked to sign the document. In no instance should
the client be requested to sign a blank release form.  The Release of
Information Form must have an indication of how long the Release of
Information Form is valid or when it expires.

FEES FOR COMPLETING REPORTS

The IL program does not typically cover the cost of obtaining an eye
report for the purpose of determining eligibility.  If a doctor’s
office refuses to provide the information without being paid, the VRT
is encouraged to discuss options with the client about independently
requesting the information.  This applies to other information
generated outside the agency as well.

FEES FOR MISSED APPOINTMENTS

If a medical or low vision practitioner sets aside a time specifically
to evaluate our client, and the client does not keep the appointment,
the client will be responsible for the charges associated with the
missed appointment.  The practitioner is entitled to a fee for the
time that was scheduled.

A practitioner must do each of the following to be paid for time
scheduled for a client who did not keep the appointment:
1.	Take the initiative to bill MCB for the missed appointment,
2.	Affirm that the agency or the client did not cancel the appointment
within the time limits posted in the office, printed on an appointment
card, or stated by the receptionist when the appointment was made, and
3.	Assert that it was not possible for the practitioner to reschedule
another patient for the time set aside, or that considerable
preparation time was required for the appointment.

HOSPITAL AND MEDICAL RECORDS

The medical report form is not required by the IL Program. However,
the medical information in the IL Open form is important for the
completion of federal reports and should be obtained during one of the
initial interviews.
 If a client will be attending MCBTC or if the medical is requested
for other reasons, existing medical records should be the first choice
in securing medical data (when they are available and will meet
program requirements) because of the potential cost savings.  The
length of time required to obtain medical records must be considered.
Long delays in providing client services do not justify minimal cost
savings.

When  requesting  medical  records,  it  is  important  to  specify
the conditions  and  procedures  about  which  you  are  interested
in receiving information. This may shorten processing time and reduce
the amount of irrelevant material which might otherwise be sent.

Although seldom needed, the general medical examination can be one of
the diagnostic tools used in determining services needed and for
identifying secondary disabilities.  The examination is to be
performed by a licensed physician.

LOW VISION SERVICES

GUIDELINES FOR LOW VISION EVALUATION

The process of low vision services is not a process of restoration of
vision; it is the process of enhancing residual vision through the use
of specific prosthetic aids and appliances. The low vision process
should be used as a beneficial process on its own merits, and not as
an alternative to or substitute for the client learning the skills of
blindness.

Many IL clients would likely benefit from a full low vision evaluation
by a low vision specialist.  Keeping this in mind the VRT should
perform a basic functional low vision assessment in the client’s place
of residence and provide guidance to the extent possible to enable the
client to take full advantage of current vision.  Equipment may be
provided for basic low vision devices.  If there are issues related to
the client’s outcomes from the functional assessment, the VRT may
consider sending the client for a full low vision evaluation if it
appears this additional service and evaluation is necessary.  This
functional assessment by the VRT is not intended to be a substitute
for qualified low vision services from the low vision practitioner.

When making a referral for a low vision evaluation, a copy of the
client's eye examination report should be included with the
authorization. The VRT should also include any information which might
be helpful to the examining practitioner such as the goals and
objectives of the client.

To the extent possible, when arrangements are made for a low vision
evaluation, the VRT may be present. Attendance at an appointment to
dispense devices may be attended based on the judgment of the VRT.

PAYMENT FOR LOW VISION SERVICE

Payment rates for low vision evaluations will be based upon units and
may vary from year to year. Cost for service may include the examining
cost for the initial evaluation, and follow-up evaluations, and the
cost for dispensing or fitting of any aid. As with all comparable
benefits, the client’s insurance, including Medicare and Medicaid
should be considered primary and MCB IL secondary. A recommendation
from the client’s eye care specialist for low vision services will
enable billing to Medicare for a significant portion or the basic cost
of the evaluation.  This can be requested by the VRT or the client.
The evaluation authorization should include only the charges for the
services/evaluations.  A written report must accompany all invoices
for low vision services.  A separate authorization needs to be issued
for the cost of equipment or devices.

TRANSPORTATION NECESSARY TO PARTICIPATE IN TRAINING

When a client requires transportation during the IL process, and is
without resources, assistance with the cost of transportation may be
provided.  The maximum amount to be reimbursed shall be the standard
State rate based on a map mileage program such as Map Quest and shall
cover one round trip for the client.  The trip shall be from the
client’s home to the training location.  If the client chooses to take
public transportation such as the bus or train, a round trip ticket
will be provided.  Only one round trip of the client’s choosing is to
be provided.

PEER COUNSELING/IL SUPPORTS

Peer counseling/support is inherent in all phases of the IL process.
It begins at the time of the initial interview and continues until
case closure. The objectives vary at the different stages of the IL
process, depending upon the client's need at each stage. In the early
stages, the objectives of counseling/support are to learn more about
the client, gather data which will assist in the development of an IL
program/plan, help the client clarify individual goals, and assist the
client in becoming active in planning.

When diagnostic data has been gathered, the focus will be on the
development of the IL objectives, IL plan, and necessary services to
achieve these objectives.

When training or restoration is nearing completion and the client is
approaching the time when she/he will be ready for closure, the
emphasis of counseling/support will be in assisting the client to
understand adjustments that may be necessary, resolving feelings about
new responsibilities and demands, etc.

TRAINING

The goal for all MCB IL clients is the greatest degree of independence
desired by the client.  Training should not be provided when the
client has already met this goal.

IL training in any individual case is furnished to a client to the
extent necessary to achieve his/her IL goals and objectives. Training
includes personal adjustment and other training which contributes to
the individual’s ability to achieve IL goals. It covers training
provided directly by MCB or procured from other public or private
training facilities including rehabilitation facilities and workshops.
MCB will provide training materials to clients when such materials are
necessary.

If the client expresses interest in employment, the VRT should obtain
the involvement of the VR counselor to pursue services through the
Vocational Rehabilitation Program.  After the client has completed IL
goals and training, the case should be closed in the IL Program.

TRAINING/DEMONSTRATION KIT

The VRT may maintain a collection of materials for the purposes of
training clients.  The kit contents may vary from one VRT to another
and are to be used to train clients, provide assessment, and aid in
outreach activities.

SKILLS TRAINING

Skills training that is to be provided must be documented in the Part
B Plan or in the case notes (OB).  Skills training include training
for any one or more of the following reasons:
1. To assist an individual in acquiring habits, attitudes, and skills
that will enhance independence
2. To develop habits and to orient the individual to a more independent setting.
3. To provide skills or techniques enabling the individual to overcome
barriers to independence resulting from vision loss.

The most frequent source of Skills training is through the VRT, Mini
Adjustment Program, and/or the Michigan Commission for the Blind
Training Center.

Referrals for skills training service are to be made by completing a
referral form and forwarding along with pertinent medical information
to the training facility. Any special request should be clearly
identified, and specific services requested where they are needed.

Initially, skills training at the Michigan Commission for the Blind
Training Center (MCBTC) will be for a period of 4-6 weeks. The VRT
should be present at a staffing at the facility or, if this is not
practical because of distance, be in phone contact with the facility
to review the planned program for the client, at which point
additional training time may be scheduled.  The skills training will
be based on the informed choice of the client with assessment by the
field VRT and MCBTC staff providing assistance.  It is expected that
the client at MCBTC will be scheduled in goal-appropriate classes at
least 75% of the available class hours each day.  Although Braille,
mobility, and computers may be valuable skills, many IL Program
clients may need only an exposure to these skill areas.  Clients are
not required to participate in a class if it does not fit their IL
goals.  It is expected that their MCBTC training programs will be
individualized to fit their specific needs and informed choice.

HOME TRAINING AND READING BRAILLE

The Hadley Correspondence School For the Blind, Inc., at Winnetka,
Illinois, offers instruction in the reading of Braille, and study
courses in Braille by correspondence to adults who wish to continue
their education at home. Information and catalogues will be sent on
request. Use of this resource in IL Programs is strongly encouraged.

ORIENTATION AND MOBILITY SERVICES

Orientation and Mobility skills are a vital component to independence.
 The IL PROGRAM may provide O&M training such as sighted guide and
protective techniques for safe indoor travel.

DEAF/BLIND

INTERPRETER SERVICES FOR THE DEAF

The MCB Deaf/Blind unit should be contacted for guidance and
suggestions, although this unit is provided essentially for the
vocational rehabilitation client. The provision of interpreter
services for hearing impaired individuals who require or request this
assistance is mandated by the Rehabilitation Act of 1973. The client's
ability to communicate and desired mode of communication should be
determined before the diagnostic phase begins to ensure that needed
interpreter service can be arranged.  The client's ability to
communicate and the desired mode must be recorded in the case file at
the time of the intake interview.

The agency will pay for the cost of interpreter services on an hourly
basis if they are not available through a comparable benefit program
in the community.

The function of the interpreter should be as a facilitator of
communication between deaf and hearing persons. The interpreter who
abides by the Registry of Interpreters for the Deaf code of ethics
will maintain an impartial attitude during the course of the
interpreting service and avoid interjecting his/her own views into the
conversation.

The usual manner of interpreting is through manual language. However,
oral interpreters may be employed if they are more appropriate for or
requested by the deaf person. The interpreter should be told before
the interview session of the deaf person's educational and language
levels, as well as whether the onset of deafness was before or after
she/he learned to talk.  Time should be allowed for the interpreter
and client to become acquainted before the actual interpreting
session, thus allowing the interpreter to become aware of the client's
language level and sign system. The agency may reimburse the
interpreter for this service.

Payment for interpreter service is made on an hourly basis.
Assignments of two or more weeks may be negotiated.

SIGN LANGUAGE AND SPEECH READING TRAINING

The agency may provide for training to improve skills in speech
reading or sign language if it is necessary to improve the
communication skills of a hearing-impaired individual. Close attention
must be paid to the type and progression of vision loss before
arranging for this type of service. In arranging for this type of
training, it is important for the VRT to determine that the intended
trainer is qualified. In most areas speech and hearing centers can
usually refer a qualified trainer for speech reading.  On a statewide
basis the Michigan Department on Deafness and Hard of Hearing, in
Lansing may also be able to provide the name of qualified speech
reading trainers (speech therapists).

Manual skills training for hearing-impaired persons without a language
base is a very complex service. Nationally there are few qualified
resources for this type of training. Before this service is
considered, consultation should occur with the IL Program supervisor.
As with other types of training programs, the VRT must thoroughly
investigate the availability of similar benefit programs in the
community before providing the cost of speech reading or sign language
training.

AUTHORIZATIONS TO PROVIDE SERVICES

MCB regulations require that a vendor be given a written authorization
prior to the purchase of a service.  Authorization and notation in a
case narrative is to be completed as to the cause and action which was
taken.

COMPARABLE BENEFITS

Comparable benefits are any services or equipment available through a
program or funding source other than MCB.  Whenever possible, the VRT
should use comparable benefits as a primary source for services or
equipment and MCB should be secondary.  Examples of comparable
benefits include Veterans benefits, Medicare, Medicaid, client’s
insurance, etc.  Community partners and their services should also be
explored and used when possible.

CASE STATUSES

The following statuses are used in the IL PROGRAM:
Pre-active (System status 00): Client has been referred for services;
case is in status 00 prior to any contact or services being provided.
Active (System status 02): The case is placed in status 02 as soon as
possible after any services have been provided to the client.  A
signed application, IL Plan, or Plan waiver is not required for the
case to be in status 02.
Closed (System status 08): Client’s case is closed.

Generally, a broad definition of “services provided” is used and may
include Information and Referral, Communications, an introduction to
the cane, introduction to Braille, or similar areas of service
provision.  It is important not to lose data by using a definition of
“services” that is too narrow.  For example, a client who receives a
visit from a VRT who explains services, signs the client up for
Talking Books, and shows the client how to use a signature guide has
been provided with significant services.


CASE NOTES

A case note is a written synopsis or update of services provided to
the client.  It should include VRT/client interaction since last case
note, teaching skills provided, adaptive equipment provided, future
planning, other pertinent information related to the client’s progress
toward the goal of increased independence.  Case notes must be made at
least every 90 days.  Case notes should also be written to record any
activity that occurs on behalf of the client including written and
verbal communications.

CLIENT RECORDS
The client's paper file and the records it contains are the center
around which all casework activity revolves.  The file contains:
A.	Basis on which eligibility for services is determined
B.	Documentation to support services provided and actions taken
C.	Fiscal documents
D.    Forms   containing   agency   and   client's   signatures
which provide   a   legal   basis   for   expenditure   of   funds.

To ensure continuity of services if a client's case must be
transferred accurate and complete case recording is necessary.
Technical accuracy is important so files can satisfactorily undergo an
audit. Most important, good case recording and accurate maintenance of
file materials are vital tools in the provision of quality services to
clients of the Michigan   Commission for the Blind's IL PROGRAM.  All
documentation in case record should be listed with most current
information on top.  Forms should be placed in case record in the
following order: Demographic, Application, Eye report, Eligibility,
Other system forms (optional), Case Note History (optional),
Referrals/Referral reports, Correspondence, and Financial

 CASE RECORD

At a minimum, the electronic case record should contain the following:
Demographic
IL Application
IL Open
IL Services
Eye Report
IL Eligibility (if appropriate)
Case Notes
Closure Form (after closure)

At a minimum, the paper file should contain the following:
Demographic
IL Application
Eye Report documentation if scanned into electronic system
IL Eligibility (if client is eligible)
Any other forms with signature or generated outside MCB

If applicable, the following should also be placed in the paper file:
Financial information such as packing slips, paid authorizations,
vendor invoices, etc.
Training reports such as those generated by MCBTC, mini adjustment, or
outside trainers.

In those cases which are reopened after closure, all material which
does not apply to the presently open case is to be placed in a
separate section and labeled "OBSOLETE".  Obsolete material may be
used in the currently opened case for comparison, rationale, etc., and
reference made to the material in the obsolete packet where
appropriate.  The VRT, with the assistance of the administrative
support person, is responsible for keeping files in proper order.

CASE CLOSURE

Closure of a client’s case occurs when it has been determined that
planned IL services have been completed or are no longer appropriate.
Reasons for closure may include completion of goals, relocation,
withdrawal, death, ineligibility, or other reason that services are no
longer being provided.
The IL Services Form should be updated and the IL Closure Form
completed in the electronic case file.  Status 08 is the status used
for case closure.

All clients should be notified of the reason their case is being
closed and that they have the right to appeal the closure decision.
Further, they must be advised of their right to re-apply for MCB IL
services in the future and a reference to the Client Assistance
Program.
CLOSURE AFTER EVALUATION

A client may be closed as ineligible if no reasonable expectation
exists that IL services will aid the client's ability to live more
independently.  The client must be informed that his/her case is being
closed. The reason for closure must be clearly stated. It must also
contain a statement of the client's right to appeal and clearly
outline the appeal procedure. A copy is provided to the client and a
copy must be retained in the case file. A copy may be sent to the
referral source if it appears appropriate.

Cases may be closed for reasons other than ineligibility. These are:
1. Inability to locate a client. If the reason for closure is "Unable
to Locate", the case file must show the following efforts to make
contact:
a. Telephone calls to the client's residence at appropriate hours of
the day, with no response
b. Efforts to contact the client through individuals identified as
contact persons on the Demographic Form.
c. Contact with the referral source if appropriate
d. Letter to the client requesting contact
2. Client's refusal of IL services.
3. Failure to cooperate.  Clients who continually fail to keep
appointments and/or who do not follow through with arrangements made
for and explained to them may have their cases closed
4. Death.

The reason for closure should be thoroughly documented with date in
the case file to support the closure decision.

SERVICES AFTER REMOVAL OF DISABILITY

In cases where vision is restored and the client is no longer eligible
for MCB IL services and support, the services which are in progress
will be completed if desired by the client, and the case will be
closed.  If requested by the client, the VRT may make a referral to
the local Center for Independent Living (CIL).

INTERRUPTION OF SERVICES

If an interruption in services occurs, the case record should reflect
this change.  When the client returns for services, the VRT and client
should evaluate the client’s need for or interest in continuing
services.  If the client does not seem interested in continuing
services at this time, his/her case may be closed.  See Item
“Reopening a Closed Case”.

REOPENING A CLOSED CASE

The VRT may find that an individual referred for services was once a
client of MCB.  Reapplications frequently result from a change in the
client's vision.  To reopen a new case, a new application must be
signed and eligibility re-established.

Cases may be reopened in situations where there has been a significant
change in vision or living situation.  Generally, cases that require
additional training are reopened.  The goal of the IL PROGRAM is
independence, and reopening a case simply to replace equipment is
counterproductive to this goal.

RECORDS MAINTENANCE

Client case records must be protected at all times to ensure
confidentiality of material. They should be kept where they are
accessible to staff only. At the end of the day, or any time when an
office area is unattended files should be placed inside a filing
cabinet. Client files should be locked up, if at all possible when the
office area is unattended.
Client files should not be removed from IL Program office except:
1. When requested by the Central Office
2. When necessary for consultation with the client or another agency
3. When subpoenaed.

When a client file folder is removed from an office cabinet, an "OUT
CARD" is to be completed by the person removing it. The "OUT CARD"
should have the client's name and the name of the individual removing
the file.

Destruction of files will be completed in accordance with current
departmental guidelines.  The paper file is maintained on site for 3
years after date of closure, Sent to the Records Center for an
additional 2 years, and then destroyed.  The electronic file is
maintained for 5 years of inactivity after the case is closed.

CONFLICT RESOLUTION
An individual or his/her representative may attempt to resolve any
issues regarding his/her case by discussing the circumstances with the
VRT and/or the VRT’s supervisor.  If at any time an individual or
his/her representative is dissatisfied with any determinations made by
his/her VRT, he/she or his/her representative may request an informal
Administrative Review conducted by a Michigan Commission for the Blind
administrator, a formal Fair Hearing conducted by a Department’s
Administrative Law Judge or Mediation utilizing mediators from the
Michigan Supreme Court Community Dispute Resolution Program. In the
case of Mediation or a Fair Hearing, the individual or his/her
representative will be provided an opportunity to select from at least
two qualified professionals to handle the proceedings. A request for
any, or all, of these processes may be initiated in the form of a
letter or phone call to the Michigan Commission for the Blind Hearings
Coordinator. The Michigan Commission for the Blind will pay for the
administrative costs of these services.
If a Fair Hearing is requested, it will be conducted within 60
calendar days of the request. The Administrative Law Judge will
provide a report of his/her findings and a decision to the Michigan
Commission for the Blind and to the individual or his/her
representative within 30 calendar days of the completion of the Fair
Hearing. This decision must be based on the provisions of the approved
State Plan, the provisions of the 1998 Amendments to the
Rehabilitation Act, Public Act 260, and the Michigan Commission for
the Blind policy.
Either party may request a review of the Administrative Law Judge’s
decision by the Department Director within 20 calendar days of the
issuance of that decision. An individual or his/her representative
must request this review in writing to the Michigan Commission for the
Blind Hearings Coordinator. The Department Director has up to 20
calendar days to notify an individual or his/her representative if a
review of the decision is being conducted. The Department Director
cannot delegate the responsibility for this decision. During this
time, both parties may submit additional evidence and information
relevant to the final decision under review. The Department Director
may not overturn the decision or any part of the decision that
supports the individual’s position unless the Department Director
concludes, based on clear and convincing evidence, that the
Administrative Law Judge’s decision is clearly erroneous on the basis
of being contrary to the laws cited above. If notice is not served,
the Administrative Law Judge's decision is final. Within 30 calendar
days, the Department Director will notify the individual or his/her
representative of the final agency decision and the grounds for the
decision, in writing. The final decision, either by the Administrative
Law Judge or the Department Director, if a review is conducted, will
be implemented pending civil action filed by either party in any state
or federal court with competent jurisdiction. If an action is filed,
the court shall review all pertinent information, hear additional
evidence if requested by either party, render a decision based on the
preponderance of the evidence, and grant such relief as the court
determines appropriate.
If an Administrative Review is requested, a Michigan Commission for
the Blind administrator not directly involved with the case will be
assigned to review the information and make recommendations for
possible resolution of the issue. This review will be conducted within
10 days of the request, and recommendations will be made within 10
calendar days of when the Administrative Review was conducted.
Recommendations arising are not binding to either party. An
Administrative Review shall in no way deny or delay an individual’s
right to a Fair Hearing.
Mediation is another form of dispute resolution that may be requested
by an individual or his/her representative with an unresolved issue
regarding his/her case. This process is voluntary on the part of both
parties. Entering into the Mediation process will in no way deny or
delay the Fair Hearing process. The mediation process should commence
within 20 calendar days of the request and in a location convenient to
both parties. Mediation proceedings are confidential and may not be
used by either party as evidence during any subsequent due process
hearing or civil proceeding. Parties may be asked to sign a
"confidentiality pledge" before entering the process. If an agreement
is reached during the Mediation process, the parties will receive a
written copy within 20 calendar days of the agreement.

CLIENT ASSISTANCE PROGRAM (CAP)
The Client Assistance Program is available to assist individuals in
resolving disputes with Michigan Commission for the Blind client
services. The Client Assistance Program staff will also answer
questions and provide information regarding agency services. The
following are the primary objectives of the Client Assistance Program:
A. To provide information, advice and clarification to individuals
about their rights, responsibilities, and the services available from
the Michigan Commission for the Blind;
B. To advocate for the fair and mutually satisfactory resolution of
individual complaints including assistance in the appeals process.
C. To report to management on the type and frequency of individual
complaints, dissatisfactions and misunderstandings for program
assessment purposes.
The VRT is to make individuals fully aware of the services of the
Client Assistance Program at the time of application and at case
closure. Clients must also be informed of the Client Assistance
Program phone number 800-292-5896.

CONFIDENTIALITY

The following information is taken from the MCB Policy Manual 6-09:
The Michigan Commission for the Blind shall safeguard the
confidentiality of all personal information in our possession
regarding an individual. Information about an individual will be
shared only with the individual and other parties upon written
directions from the individual or for purposes of furthering the
individual's IL program. There are two exceptions to this policy, as
follows:
A. Where ordered by a court or law enforcement agency staff, after
having consulted with the Attorney General's Office through the
Director of Client Services, and having been advised to comply; and
B. For the protection of the individual or others when the individual
poses a threat to his or her safety or to the safety of others.
However, when information of a sensitive nature may be potentially
harmful to the individual, this information must be released through
the appropriate counselor/teacher or supervisor. This policy shall be
thoroughly discussed with the individual at the time of application.
By signing the application, the individual is indicating he/she is
willing to abide by this policy. Information from substance abuse
programs (according to Public Act 56, Section 18) and the Social
Security Administration must always be removed before information is
shared with courts or record-copying services.
Subpoenas should be sent immediately to the Director of Client
Services for use in consultation with the Attorney General's Office.
Before testifying or providing records in a case, the
counselor/teacher should read the following statement:
"The Michigan Commission for the Blind operates under federal and
state legislation which requires case information about a client to be
held strictly confidential. Please refer to Section 85 of Act 314 of
the Public Acts of 1915 (Judicature Act), Section 27.934 and 27a.2165
of the Michigan Statutes Annotated."
Then, if ordered, we must comply with the court.

DATA SHARING WITH CLIENTS, COURTS, AND/OR ATTORNEYS

The following information is taken from the MCB Policy Manual 6-09:
If an attorney representing the client has the client's written power
of attorney, agency prepared case file material only may be reviewed
and copied. Data purchased or obtained from another source must be
requested from the originator. The same rule would apply to any
individual having power of attorney in a client's behalf. The person
who has the power of attorney will present written evidence of this
fact when requesting access to the Commission for the Blind Records.
This evidence does not follow any specific format but will always
contain the client's signature.

If an adversary attorney is seeking access to file material, we can
permit the complete file, under subpoena, to be brought into court.
The presiding judge may then make information available. EXCEPTION:
Any material from the Social Security Administration, Veterans
Administration, or substance abuse agency must be removed before the
file is given to the court. The judge should be advised of this.

LEGAL ASSISTANCE
The following information is taken from the MCB Policy Manual 6-09:
“Counselors/teachers shall identify complex and potentially
controversial legal issues that require special guidance and
consultation. After identifying such issues, the Michigan Commission
for the Blind State Director or the Director of Client Services shall
work with appropriate Departmental staff in securing the appropriate
assistance from the Office of the Attorney General.
Requests for formal Attorney General opinion and letters of advice on
issues of general applicability shall be made to the Department
Director who, in consultation with the Michigan Commission for the
Blind, will determine whether to forward the request to the Office of
the Attorney General. The purpose of this policy is to enable the
Michigan Commission for the Blind and the Department to resolve
complex legal issues in a timely and cost-effective manner.

Legal assistance and/or legal fees are not services provided to
individuals {by MCB}.”

FORMS

INDEPENDENT LIVING

DEPARTMENT OF
LICENSING AND REGULATORY AFFAIRS
CONSUMER SERVICES DIVISION
MICHIGAN COMMISSION FOR THE BLIND (MCB)

IL Application for Services

Name: 	
SSN: 	

CLIENT NAME expressed a willingness to participate in the Independent
Living Program of the Michigan Commission for the Blind. This person
has also been informed of the Client Assistance Program which can be
reached at 1-800-292-5896.


	

Client									Date

IL Case Information Form

Caseload: 	

Referral Date 		SSN 	
Last Name 		First Name 			   MI
 			
Current Addresses:	
Street: 	
Suite/Apt:		Zip: 	
City: 		State: 	
County: 	
Mail Here? 		Main Residence?	
Archive? 	  	Archived Date: 	

Telecom: 	 Phone # 	
Home: 		 	 	
Cell: 		
Work: 		
Video: 		
TTY ? 	  	
VRS IP: 	
E-mail: 	

Gender and Ethnicity
Gender:

Race/Ethnicity: 	
White?
Black or African American?
Native Hawaiian or Pacific Islander?
American Indian or Alaska Native?
Asian?
Hispanic Origin or Latino?

Impairments

Primary Impairment
Impairment:

Secondary Impairment
Impairment:

Other Impairments
Impairment 1:

Independent Living Goals
IL Goals					SET		MET		CANCELED
Self-Advocacy / Self-Empowerment	  	  	
Communication	  	  	
Mobility / Transportation	  	  	
Community-Based Living	  	  	
Educational	  	  	
Vocational	  	  	
Self-care	  	  	
Information Access / Technology	  	  	
Personal Resource Management	  	  	
Relocation from a Nursing Home or Institution to Community-Based Living	
Community / Social Participation	  	  	
Other	  	  	

Independent Living Services
IL Services						Provided
Advocacy / Legal Service: 	
Assistive Technology: 	
Children's Services: 	
Communication Services: 	
Counseling and Related Services: 	
Family Services: 	
Housing, Home Modifications, and Shelter Services: 	
Information and Referral Services: 	
IL Skills Training and Life Skills Training: 	
Mental Restorative Services: 	
Mobility Training: 	
Peer Counseling Services: 	
Personal Assistance Services: 	
Physical Restoration Services: 	
Preventive Services: 	
Prostheses, Orthotics, and Other Appliances: 	
Recreational Services: 	
Rehabilitation Technology Services: 	
Therapeutic Treatment: 	
Transportation Services: 	
Youth / Transition Services: 	
Vocational Services: 	
Other Services: 	Y

Access Questions
Access		Client Requires Access	Client Achieves Access
(A) Transportation

(B) Health Care Services

(C) Assistive Technology

Closure Information
Client Continues to Use Majority of Acquired Skills?

Level Of Independence Has:


If Decreased, Why?     Diminished Health     Additional Vision Loss
   Support System Intervened     Personal Choice     Other

Reason for Closure:
  	One or More Goals Achieved
  	Moved
  	Withdrew
  	Died
  	Other:	
 		
Closure Date:	
Approval Date:	

Client Agrees to Closure?
If No, Please Explain.


Client was provided with a copy of the Satisfaction Survey:
If No, Please Explain.


IL Services Prevented Entry into Nursing Home?


DEPARTMENT OF
LICENSING AND REGULATORY AFFAIRS
CONSUMER SERVICES DIVISION
MICHIGAN COMMISSION FOR THE BLIND (MCB)

IL Service Plan

 Name: 	

Case Number:

Plan Number:


Plan begins on 	and is estimated to end on

Plan Estimated Cost:

Agency Estimated Cost:

Goal:	

Method of Evaluation:

Notes

Date:


Note:


Category:
Service:
Vendor:
No. Units: 		Unit: 		Unit Price: 		=

Funded By (Pick one or more when applicable):

Cost:

Service Detail:


Service Dates:

Improved Access Needed for Independence:
Requires
  	Transportation
  	Health Care
	Assistive Technology

Client Comments:

Implementation of this plan in part or full is contingent upon
supervisory approval and availability of funds.


DEPARTMENT OF
LICENSING AND REGULATORY AFFAIRS
CONSUMER SERVICES DIVISION
MICHIGAN COMMISSION FOR THE BLIND (MCB)

IL Service Plan Progress Report
Name: 	
Case Number:

Plan begins on (BEGIN DATE) and is estimated to end on (END DATE)

________________________________________
Goal:	

Outcome:
Outcome Date:

Progress Notes
 Date:
 Note:

________________________________________
Category:
Service:
Vendor:

Outcome:
Outcome Date:

Functional Gains:

Progress Notes

Date:

Note:

________________________________________

All goals/services have been completely provided on:	

________________________________________

Access	Client Requires Access	Client Achieves Access
(A) Transportation	  	
(B) Health Care Services	  	
(C) Assistive Technology		

Client Continues to Use Majority of Acquired Skills? Y/N

Level Of Independence Has:

If Decreased, Why?     Diminished Health     Additional Vision Loss
   Support System Intervened     Personal Choice     Other

Reason for Closure:
Y/N	One or More Goals Achieved
Y/N	Moved
Y/N	Withdrew
Y/N	Died
Y/N	Other:	
 		
Closure Date:	
Approval Date:	

Client Agrees to Closure? Y
If No, Please Explain.


Client was provided with a copy of the Satisfaction Survey: Y
If No, Please Explain.


DEPARTMENT OF
LICENSING AND REGULATORY AFFAIRS
CONSUMER SERVICES DIVISION
MICHIGAN COMMISSION FOR THE BLIND (MCB)

MCB Purchase Request

Date of Authorization: 	RSA Authorization Number:

Requesting RSA staff: 	Phone Number: 	Fax Number:
		
Address:


Purchase for RSA Client - Name:                          ID Number:


Vendor Name: 	Vendor's EIN or SSN:
	
Vendor's Contact Person: 	Phone Number:
	
Vendor Address:



	

Service Description:

Service Begin Date: 	
Service End Date: 	
	Account #: 	
Account Name: 	
	Index: 	
P C A: 	


Quantity: 	Unit: 	Unit Price: 	Total Cost:
			
Agency Object: 	Void After: 	
	
Total: $0.00
Comments:

This purchase is authorized pursuant to   by.

 	 	Approved? 	  	
 	 Authorized By:

Please Submit invoices to the authorizer and Address above.
Authorization is hereby granted to provide the services described
above. Payment can only be made for the services authorized and at the
rates authorized.  If there is any change required in this
authorization the Vendor must contact the authorizer first. Payment
will be made promptly upon receipt of properly prepared invoices.

Authority: P. A. 260 of 1978, as amended 	
Completion: Mandatory 	
Penalty: Services may not be provided 	


Authorization Specification 1



OLDER BLIND

ILOB Case Information Form
Caseload: 	


Referral Date 		SSN 	
Last Name 		First Name 	                        MI

Current Addresses:	
Street: 	
Suite/Apt:		Zip: 	
City: 		State: 	
County: 	

Mail Here? 	  	Main Residence?	
Archive? 	  	Archived Date: 	
	
Telecom: 	 Phone # 	
Home: 		 	 	
Cell: 		
Work: 		
Video: 		
TTY ? 	  	
	 	
VRS IP: 	
E-mail: 	

Gender and Ethnicity
Gender: 	

Race/Ethnicity: 	   White?
 	   Black or African American?
 	   Native Hawaiian or Pacific Islander?
 	   American Indian or Alaska Native?
 	   Asian?
 	   Hispanic Origin or Latino?

Additional Information

Marital Status:

Highest Level of Education Completed:

Type of Living Arrangement at Time of Intake:

Setting of Residence at Time of Intake:

Source of Referral: 	

Visual Impairment at Time of Intake:

Onset of Significant Vision Loss (when loss began to affect
performance of daily activities):

Major Cause of Visual Impairment:

Other Impairments:

Other Impairments 1:

Independent Living Services
ILOB Services	Provided
Vision screening /examination /evaluation: 	
Surgical/therapeutic treatment: 	
Provisions of AT devices and aids: 	
Provision of AT services: 	
Orientation and Mobility training: 	
Communication skills: 	
Daily living skills: 	
Support services (reader, transport, attendant, etc) 	
Advocacy training and support networks: 	
Counseling (peer, individual and group): 	
Information, referral and community integration: 	
Other IL Services: 	
Information and Referral: 	
Independent living and adjustment skills training: 	

Program Outcomes/Performance Measures
*(required when applicable)
 		
1) 	  	If the individual received O&M, the individual gained or
maintained their ability to travel safely and independently in their
residence or community as a result of services (Y or N)
	
 		
2) 	  	If the individual received O&M, Communication Skills, or Daily
Living Skills Training, the individual gained or successfully restored
or maintained ability to engage in customary life activities as a
result of services (Y or N)
	
 		
3) 	  	If the individual received AT (assistive technology) services
and training, the individual regained or improved abilities previously
lost or diminished as a result of vision loss (Y or N)

4) To maintain their current living situation as a result of services,
the individual reported feeling that they have  	 greater control and
are more confident
	
 no change in feelings of control and confidence
	
 less control and are less confident
	
 experienced changes in lifestyle for reasons unrelated to vision loss
	
Closure Information
Client Continues to Use Majority of Acquired Skills?

Level Of Independence Has:
If Decreased, Why?     Diminished Health     Additional Vision Loss
   Support System Intervened     Personal Choice     Other

Reason for Closure:
  	One or More Goals Achieved
  	Moved
  	Withdrew
  	Died
  	Other:	
 		
Closure Date:	
Approval Date:	

Client Agrees to Closure?
If No, Please Explain.


Client was provided with a copy of the Satisfaction Survey:
If No, Please Explain.



DEPARTMENT OF
LICENSING AND REGULATORY AFFAIRS
CONSUMER SERVICES DIVISION
MICHIGAN COMMISSION FOR THE BLIND (MCB)

ILOB DAILY LIVING ASSESSMENT

I. CLIENT INFORMATION
  Assessment Only
SSN 	
Last Name 	First Name 	   MI
Date of Contact 	
  	
Current Addresses:	
Street: 	
Suite/Apt:		Zip: 	
City: 		State: 	County: 	
Mail Here? 		Main Residence? 	
Archive? 	  	Archived Date: 	

Telecom
Home Phone:
Cell Phone:
TTY (Y/N)?
VRS IP:
E-mail:

II. ADJUSTMENT AND COMMUNITY INTEGRATION FUNCTIONAL ASSESSMENT

Assessment:

Entry Level:
Goal Level:

Comments:
III. UNDERSTANDINGS
	I have discussed and understand the agency's policies regarding my
rights and responsibilities.
	I understand that this plan will be reviewed periodically to
determine progress toward achieving stated goals. When such reviews
indicate that goals can no longer be reasonably expected to occur, the
independent living program will be terminated.
	I understand that this is not a legal document and is subject to the
availability of funds.
	I have discussed and understand that I will contact my teacher when I:
•	want to change the agreed-upon goal;
•	want to change services, time frames, etc., in this plan; and
•	decide to discontinue participating in the plan.
	I understand that my eligibility for services is based on a
determination that I:
•	have a visual impairment which constitutes, or results in, a
substantial impediment to performing activities of daily living.

Client's Views:


  	  	
Client/Representative/Guardian Signature 	  	Date
  		
  	  	
Instructor Signature 	  	Date
  	  	

Teacher's comments regarding client's need for Services: (e.g.
education, environment, family situation, etc.)


DEPARTMENT OF
LICENSING AND REGULATORY AFFAIRS
CONSUMER SERVICES DIVISION
MICHIGAN COMMISSION FOR THE BLIND (MCB)

ILOB DAILY LIVING ASSESSMENT

I. CLIENT INFORMATION
  Assessment Only
SSN 	
Last Name 	First Name 	   MI
Date of Contact 	
  	
Current Addresses:	
Street: 	
Suite/Apt:		Zip: 	
City: 		State: 	County: 	
Mail Here? 		Main Residence? 	
Archive? 	  	Archived Date: 	

Telecom
Home Phone:
Cell Phone:
TTY (Y/N)?
VRS IP:
E-mail:

II. ORIENTATION AND MOBILITY FUNCTIONAL ASSESSMENT

Assessment:

Entry Level:
Goal Level:

Comments:

Client's Views:

III. UNDERSTANDINGS

	I have discussed and understand the agency's policies regarding my
rights and responsibilities.
	I understand that this plan will be reviewed periodically to
determine progress toward achieving stated goals. When such reviews
indicate that goals can no longer be reasonably expected to occur, the
independent living program will be terminated.
	I understand that this is not a legal document and is subject to the
availability of funds.
	I have discussed and understand that I will contact my teacher when I:
•	want to change the agreed-upon goal;
•	want to change services, time frames, etc., in this plan; and
•	decide to discontinue participating in the plan.
	I understand that my eligibility for services is based on a
determination that I:
•	have a visual impairment which constitutes, or results in, a
substantial impediment to performing activities of daily living.
  	  	
Client/Representative/Guardian Signature 	  	Date
  	  	
O M Instructor's Signature 	  	Date
  	  	
O&M Instructor's comments regarding client's need for Services (e.g.
education, environment, family situation, etc.)

VIII. Referral for Low Vision Examination
To: (VR Counselor) I am recommending that a low vision examination be
initiated for Town Halloween as soon as possible. The client should be
evaluated for distance and reading aids.


DEPARTMENT OF
LICENSING AND REGULATORY AFFAIRS
CONSUMER SERVICES DIVISION
MICHIGAN COMMISSION FOR THE BLIND (MCB)

ILOB DAILY LIVING ASSESSMENT

I. CLIENT INFORMATION
  Assessment Only
SSN 	
Last Name 	First Name 	   MI
Date of Contact 	
  	
Current Addresses:	
Street: 	
Suite/Apt:		Zip: 	
City: 		State: 	County: 	
Mail Here? 		Main Residence? 	
Archive? 	  	Archived Date: 	

Telecom
Home Phone:
Cell Phone:
TTY (Y/N)?
VRS IP:
E-mail:

What assistive technologies are you familiar with and what is your
current skill level with Computer Access devices?

What is your primary access modality? (screen reading/screen
magnification/OCR/refreshable Braille, etc.)

Length of time utilizing each modality and efficiency:


II. COMMUNICATION AND INFORMATION ACCESS ASSESSMENT

Assessment:

Entry Level:
Goal Level:
Comments:

III. UNDERSTANDINGS

	I have discussed and understand the agency's policies regarding my
rights and responsibilities.
	I understand that this plan will be reviewed periodically to
determine progress toward achieving stated goals. When such reviews
indicate that goals can no longer be reasonably expected to occur, the
independent living program will be terminated.
	I understand that this is not a legal document and is subject to the
availability of funds.
	I have discussed and understand that I will contact my teacher when I:
•	want to change the agreed-upon goal;
•	want to change services, time frames, etc., in this plan; and
•	decide to discontinue participating in the plan.
	I understand that my eligibility for services is based on a
determination that I:
•	have a visual impairment which constitutes, or results in, a
substantial impediment to performing activities of daily living.
  	  	
Client/Representative/Guardian Signature 	  	Date
  		
Teacher Signature 	  	Date

Teacher's comments regarding client's need for Services: (e.g.
education, environment, family situation, etc.)


DEPARTMENT OF
LICENSING AND REGULATORY AFFAIRS
CONSUMER SERVICES DIVISION
MICHIGAN COMMISSION FOR THE BLIND (MCB)

ILOB DAILY LIVING ASSESSMENT

I. CLIENT INFORMATION
  Assessment Only
SSN 	
Last Name 	First Name 	   MI
Date of Contact 	
  	
Current Addresses:	
Street: 	
Suite/Apt:		Zip: 	
City: 		State: 	County: 	
Mail Here? 		Main Residence? 	
Archive? 	  	Archived Date: 	

Telecom
Home Phone:
Cell Phone:
TTY (Y/N)?
VRS IP:
E-mail:
Prior Rehab Training?       	

II. DAILY LIVING FUNCTIONAL ASSESSMENT

Assessment:

Entry Level:
Goal Level:
Able to identify or has a method for organizing paper money and coins?

Writes paper checks and pays bills independently?

Uses Calculator?

Uses debit / credit card independently?

Uses electronic / online banking?

Comments:

III. UNDERSTANDINGS

	I have discussed and understand the agency's policies regarding my
rights and responsibilities.
	I understand that this plan will be reviewed periodically to
determine progress toward achieving stated goals. When such reviews
indicate that goals can no longer be reasonably expected to occur, the
independent living program will be terminated.
	I understand that this is not a legal document and is subject to the
availability of funds.
	I have discussed and understand that I will contact my teacher when I:
•	want to change the agreed-upon goal;
•	want to change services, time frames, etc., in this plan; and
•	decide to discontinue participating in the plan.
	I understand that my eligibility for services is based on a
determination that I:
•	have a visual impairment which constitutes, or results in, a
substantial impediment to performing activities of daily living.
  	  	
Client/Representative/Guardian Signature 	  	Date
  		
  	  	
RT Instructor Signature 	  	Date


DEPARTMENT OF
LICENSING AND REGULATORY AFFAIRS
CONSUMER SERVICES DIVISION
MICHIGAN COMMISSION FOR THE BLIND (MCB)

ILOB Service Plan Progress Report
Name: 	

Case Number:

Total Provided Hours: 	

Goal:

Initial Assessment:
Estimated Quantity:

Entry Level:
Target Level:
Achieved Level:

Goal Detail:
Service:

Detail:

Progress Note

Date:

Pricing Tier:

User:

Skill Level:

Hours:

Cost:

Note:

All the Planned Services have been Completely Provided on:

Client Continues to Use Majority of Acquired Skills?

Level Of Independence Has:

If Decreased, Why?     Diminished Health     Additional Vision Loss
   Support System Intervened     Personal Choice     Other

Program Outcomes/Performance Measures
*(required when applicable)

1) If the individual received O&M, the individual gained or maintained
their ability to travel safely and independently in their residence or
community as a result of services (Y or N)

2) If the individual received O&M, Communication Skills, or Daily
Living Skills Training, the individual gained or successfully restored
or maintained ability to engage in customary life activities as a
result of services (Y or N)

3) If the individual received AT (assistive technology) services and
training, the individual regained or improved abilities previously
lost or diminished as a result of vision loss (Y or N)

4) To maintain their current living situation as a result of services,
the individual reported feeling that they have greater control and are
more confident no change in feelings of control and confidence less
control and are less confident experienced changes in lifestyle for
reasons unrelated to vision loss (Y or N)

Reason for Closure:
One or More Goals Achieved
Moved
Withdrew
Died
Other:

Closure Date:	
Approval Date:	

Client Agrees to Closure?
If No, Please Explain.


Client was provided with a copy of the Satisfaction Survey:
If No, Please Explain.




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