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pdfOMB Control No. 2900-0681
Respondent Burden: 1 Hour
PRELIMINARY INDEPENDENT LIVING (IL) ASSESSMENT
Privacy Act Notice: VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title
38, Code of Federal Regulations 1.576 for the purpose of educational and vocational planning and to help you make the best use of your rehabilitation benefits. This
information will not be released outside VA unless you authorize its release in writing or the disclosure is authorized under the Privacy Act, including the routine use
identified in VA system of records, 58VA21/22, Compensation, Pension, Education, and Rehabilitation Records - VA, published in the Federal Register. Your
obligation to respond is required to obtain or retain benefits. Giving us your SSN account information is voluntary. Refusal to provide your SSN by itself will not result
in the denial of benefits. VA will not deny an individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by a Federal Statute
of law in effect prior to January 1, 1975, and still in effect.
Respondent Burden: We need this information to evaluate your independent living needs. Title 38, United States Code, allows us to ask for this information. We
estimate that you will need an average of 1 hour to review the instructions, find the information, and complete this form. VA cannot conduct or sponsor a collection of
information unless a valid OMB control number is displayed. You are not required to respond to a collection of information if this number is not displayed. Valid OMB
control numbers can be located on the OMB Internet Page at www.whitehouse.gov/omb/library/OMBINV.VA.EPA.html#VA. If desired, you can call 1-800-827-1000
to get information on where to send comments or suggestions about this form.
1. FIRST, MIDDLE, LAST NAME
2. VA FILE NUMBER
3. SOCIAL SECURITY NO.
4. DATE
PART I - ACTIVITIES OF DAILY LIVING
This questionnaire focuses on types of activities related to independent living. Your responses to the questions will help
determine how much difficulty you may have had in performing these activities during the past month. By difficulty, we
mean how hard was it or how much effort did it take to do the activity because of your disability(ies). Circle the number
in the column that most closely identifies your response.
DURING THE PAST
MONTH, HOW MUCH
ITEM
DIFFICULTY DID YOU
NO.
HAVE DOING THE
FOLLOWING TASKS?
TAKING CARE OF SELF,
5
INCLUDING EATING,
DRESSING, OR BATHING
MOVING IN AND OUT OF A
6
BED OR CHAIR
WALKING SEVERAL
7
BLOCKS
WALKING ONE BLOCK, OR
8
CLIMBING ONE FLIGHT OF
STAIRS
WALKING INDOORS,
9
SUCH AS AROUND
YOUR HOME
DOING WORK AROUND
THE HOUSE SUCH AS
10
CLEANING, LIGHT YARD
WORK, OR LAUNDRY
USUALLY DID
USUALLY DID USUALLY DID
WITH HELP OR
WITH NO
WITH SOME
ASSISTIVE
DIFFICULTY DIFFICULTY
DEVICE
USUALLY DID
NOT DO
BECAUSE OF
DISABILITIES
USUALLY DID
NOT DO FOR
OTHER
REASONS
4
3
2
1
0
4
3
2
1
0
4
3
2
1
0
4
3
2
1
0
4
3
2
1
0
4
3
2
1
0
11
DOING ERRANDS, SUCH
AS SHOPPING
4
3
2
1
0
12
DRIVING A CAR, OR
USING PUBLIC
TRANSPORTATION
4
3
2
1
0
13
VISITING WITH RELATIVES
OR FRIENDS
4
3
2
1
0
4
3
2
1
0
4
3
2
1
0
14
15
VA FORM
SEP 2005
PARTICIPATING IN
COMMUNITY ACTIVITIES,
SUCH AS RELIGIOUS
SERVICES, SOCIAL
ACTIVITIES, OR
VOLUNTEER WORK
TAKING CARE OF OTHER
PEOPLE SUCH AS FAMILY
MEMBERS
28-0791
PART I - ACTIVITIES OF DAILY LIVING (Continued)
DURING THE PAST
MONTH, HOW MUCH
ITEM
DIFFICULTY DID YOU
NO.
HAVE DOING THE
FOLLOWING TASKS?
PARTICIPATING IN
MODERATE
16
RECREATIONAL
ACTIVITIES, SUCH AS
PLAYING GOLF
WRITING USING PEN OR
17
PENCIL
BENDING, STOOPING,
18
LIFTING
USUALLY DID
USUALLY DID USUALLY DID
WITH HELP OR
WITH NO
WITH SOME
ASSISTIVE
DIFFICULTY DIFFICULTY
DEVICE
USUALLY DID
NOT DO
BECAUSE OF
DISABILITIES
USUALLY DID
NOT DO FOR
OTHER
REASONS
4
3
2
1
0
4
3
2
1
0
4
3
2
1
0
19
SLEEPING
4
3
2
1
0
20
TAKING OWN
MEDICATIONS
4
3
2
1
0
21
USING TELEPHONE
4
3
2
1
0
22
HANDLING OWN MONEY
4
3
2
1
0
23
PREPARING OWN MEALS
4
3
2
1
0
24
USING TOILET
4
3
2
1
0
25
PARTICIPATING IN
VIGOROUS ACTIVITIES
4
3
2
1
0
4
3
2
1
0
4
3
2
1
0
4
3
2
1
0
4
3
2
1
0
26
27
28
29
MEMORY AND
CONCENTRATION
GETTING IN AND OUT OF
RESIDENCE
CONTROLLING
ENVIRONMENT, SUCH AS
OPERATING A FAN,
THERMOSTAT, OR TV
COMMUNICATING
ELECTRONICALLY WITH
FAMILY OR FRIENDS
COLUMN SCORE
(Add circled responses)
TOTAL SCORE FOR THIS ASSESSMENT
(Add totals in "Column Score")
30. FOR ANY ACTIVITY WHICH YOU MARKED 3 OR LOWER, PLEASE EXPLAIN
PART I - ACTIVITIES OF DAILY LIVING (Continued)
31. IN GENERAL, HOW WOULD YOU RATE YOUR OVERALL LEVEL OF INDEPENDENCE?
VERY HIGH
HIGH
MODERATE
LOW
VERY LOW
32. DO YOU HAVE A PERSONAL CARE ATTENDANT?
YES
NO
PART II - ALCOHOL/SUBSTANCE ABUSE
33. DO YOU NOW, OR HAVE YOU EVER HAD A PROBLEM WITH ALCOHOL OR DRUG ABUSE?
YES
NO
34. ARE YOU NOW ABSTINENT?
YES
NO
(If "No," complete Item 35)
35. HOW MUCH, HOW OFTEN, AND WHAT SUBSTANCE (ALCOHOL AND/OR DRUGS) DO YOU USE?
PART III - HOUSING
36. WHERE DO YOU CURRENTLY LIVE?
PRIVATE HOME
OWN
APARTMENT
HALF-WAY HOUSE
RENT
VA DOMICILIARY
HOMELESS SHELTER
OTHER (Please explain)
37. WHO LIVES WITH YOU?
LIVE ALONE
RELATIVES
LIVE WITH SPOUSE
FRIENDS
LIVE WITH SIGNIFICANT
OTHER
OTHER (Please explain)
38. ARE YOU HAVING ANY PROBLEMS IN YOUR CURRENT HOUSING OR LIVING ARRANGEMENTS?
YES
NO
(If "Yes," please explain)
39. DO YOU FEEL SAFE AT HOME AND ON THE STREET?
YES
NO
(If "No," please explain)
PART IV - PERSONAL, EMOTIONAL, AND SPERITUAL NEEDS
40. HOW MUCH CONTROL DO YOU FEEL THAT YOU HAVE IN YOUR LIFE AND THE CHOICES THAT MATTER TO YOU?
41. IN GENERAL, HOW DO YOU FEEL ABOUT YOURSELF AND YOUR LIFE?
42. HOW MUCH SUPPORT DOES YOUR FAMILY PROVIDE FOR YOU?
PART IV - PERSONAL, EMOTIONAL, AND SPIRITUAL NEEDS (Continued)
43. DO YOU HAVE ANY PROBLEMS GETTING ALONG WITH OTHER PEOPLE?
YES
NO
(If "Yes," please explain)
44. DO YOU HAVE SPIRITUAL NEEDS THAT ARE NOT BEING MET?
YES
NO
(If "Yes," please explain)
PART V - LEISURE/AVOCATIONAL ACTIVITIES
45. HOBBIES
ITEM
NO.
A. LIST YOUR CURRENT HOBBIES
B. AMOUNT OF TIME SPENT ON EACH HOBBY PER MONTH
1
2
3
4
46. ARE THERE ANY HOBBIES THAT YOU CAN NO LONGER DO?
YES
NO
(If "Yes," please explain)
PART VI - ADDITIONAL COMMENTS
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| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |