Individual Service Plan (Isp) For Individuals With Developmental Disabilities Living In The Community Template Page 11

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ACTION PLAN FOR HEALTH AND SAFETY RELATED SUPPORTS
DATE OF ACTION PLAN:
EXPECTED HEALTH AND SAFETY RESULTS:
PERSONAL CHALLENGES AND OBSTACLES THAT NEED TO BE ADDRESSED
(All listed challenges and obstacles must be addressed through action steps, teaching and support strategies and/or support plans)
SUPPORTS AND ACTION STEPS NEEDED FOR BASIC HEALTH AND SAFETY OUTCOME STATEMENTS
Identify supports the individual needs beyond those already addressed in action plans for other desired outcomes in order to stay as healthy and safe as possible. These include action steps that have
not yet been completed (i.e., actions that are past due) and action steps related to newly identified areas of support (e.g., needed specialized assessments or adaptive equipment). Action steps should
be included which address adequate supports for 1) a condition that is worsening, 2) a new diagnosis, 3) new symptoms, and/or 4) the need to obtain medical tests or evaluations. If steps address an
Assistive Technology device, refer to the Assistive Technology Inventory. This Is not intended for tracking routine medical appointments, or to duplicate supports detailed in the individual’s healthcare
plan(s).
DOCUMENTATION AND REPORTING
ACTION STEPS
FREQUENCY
STRATEGIES/WDSIs
RESPONSIBLE
TARGET
REQUIREMENTS
NEEDED
PARTY (IES)
DATE(S)
SKILLS TO LEARN AND TASKS TO DO
HOW OFTEN, HOW LONG
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
UNAVAILABLE SERVICES OR SUPPORTS
STEPS TO OBTAIN NEEDED SERVICES OR SUPPORTS
After implementing steps to obtain unavailable specialty services, if the services are still unavailable, complete a regional office intervention form and submit it to the local regional office.
NAME: ______ DOB: ____
EFFECTIVE DATE of ISP: ____
PAGE 11 OF 17
version 3/13

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