Form Ddd-1332aforpf - Individual Support Plan/individualized Family Service Plan Individual Attributes Checklist

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DDD-1332AFORPF (9-07)
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
Clear The Form
Division of Developmental Disabilities
INDIVIDUAL SUPPORT PLAN/INDIVIDUALIZED FAMILY SERVICE PLAN
INDIVIDUAL ATTRIBUTES CHECKLIST
INDIVIDUAL’S NAME (Last, First, M.I.)
DATE
FOCUS ID NO.
ELIGIBILITY
DATE OF BIRTH
ALTCS
TSC
Foster Care
DDD (only)
AZEIP
List the service(s) at the top of each column. If there are more than 5 services, attach another checklist.
In each column, provide requested information and check the attributes that must be considered when receiving the service(s).
The service amount identified on this document does not constitute approval.
All those individual characteristics/provider expertise marked with (*) are electronically matched to qualified vendors who the
individual/responsible person can select amongst.
SERVICE
SERVICE
SERVICE
SERVICE
SERVICE
Service Amount
Service need date
Qualified vendor
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Independent provider
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Auto Assign
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
List days and time you are available
to receive the service.
Who will contact potential providers
to confirm availability?
Cross streets, community and/or
city where you are located.
If you have identified the service
provider in advance, please specify.
INDIVIDUAL CHARACTERISTICS:
Autism
Cognitive Disability
Cerebral palsy
Epilepsy
At risk
Movement limitations
Vision limitations
Hearing limitations
Communication limitations
Alzheimer’s/dementia
Non-ambulatory
In-home
In-home
In-home
In-home
In-home
Location of service
Out-of-home
Out-of-home
Out-of-home
Out-of-home
Out-of-home
No preference
No preference
No preference
No preference
No preference
*Assistive technology
*Augmentative communication device
*G-tube feeding/cleaning
*Assistance with bowel and bladder care
*Positioning

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