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pdfOMB Control No. 2900-0681
Respondent Burden: 1 Hour
Expiration Date: XX/XX/XXXX
PRELIMINARY INDEPENDENT LIVING (IL) ASSESSMENT
IMPORTANT: A preliminary evaluation of Independent Living (IL) needs is to be conducted with the veteran by the VA case manager. If potential IL
needs are identified through a preliminary assessment, then a comprehensive IL evaluation is to be completed. (M28, Part IV, Subpart iv, Ch 9)
READ TO VETERAN: ACTIVITIES OF DAILY LIVING: This questionnaire focuses on Activities of Daily Living. Activities which should be
examined during the initial assessment include: Alcohol/Substance Abuse; Housing; Personal/Emotional/Spiritual Needs; and Leisure/Vocational
Activities. The veteran's responses to the questions will help determine how much difficulty the veteran may have had in performing these activities
during the past month. Difficulty is defined as how hard it was or how much effort it took to complete an activity because of the veteran's
disability(ies).
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). Check the box in the column that most closely identifies your response.
ITEM
NO.
5
6
7
8
DURING THE PAST
MONTH, HOW MUCH
DIFFICULTY DID YOU
HAVE DOING THE
FOLLOWING TASKS?
TAKING CARE OF SELF,
INCLUDING EATING,
DRESSING, OR BATHING
MOVING IN AND OUT OF A
BED OR CHAIR
WALKING SEVERAL
BLOCKS
WALKING ONE BLOCK, OR
CLIMBING ONE FLIGHT OF
STAIRS
USUALLY DID
USUALLY DID USUALLY DID WITH HELP OR
WITH SOME
WITH NO
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
9
WALKING INDOORS, SUCH
AS AROUND
YOUR HOME
4
3
2
1
0
10
DOING WORK AROUND
THE HOUSE SUCH AS
CLEANING, LIGHT YARD
WORK, OR LAUNDRY
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
14
PARTICIPATING IN
COMMUNITY ACTIVITIES,
SUCH AS RELIGIOUS
SERVICES, SOCIAL
ACTIVITIES, OR
VOLUNTEER WORK
4
3
2
1
0
15
TAKING CARE OF OTHER
PEOPLE SUCH AS FAMILY
MEMBERS
4
3
2
1
0
VA FORM
XXX XXXX
28-0791
SUPERSEDES VA FORM 28-0791, FEB 2010,
WHICH WILL NOT BE USED.
PART I - ACTIVITIES OF DAILY LIVING (Continued)
ITEM
NO.
DURING THE PAST
MONTH, HOW MUCH
DIFFICULTY DID YOU
HAVE DOING THE
FOLLOWING TASKS?
USUALLY DID
USUALLY DID USUALLY DID WITH
HELP OR
WITH NO
WITH SOME
ASSISTIVE
DIFFICULTY DIFFICULTY
DEVICE
PARTICIPATING IN
MODERATE
RECREATIONAL
ACTIVITIES, SUCH AS
PLAYING GOLF
USUALLY DID
NOT DO
BECAUSE OF
DISABILITIES
USUALLY DID
NOT DO FOR
OTHER
REASONS
4
3
2
1
0
WRITING USING PEN OR
PENCIL
BENDING, STOOPING,
LIFTING
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
26
MEMORY AND
CONCENTRATION
GETTING IN AND OUT OF
RESIDENCE
4
3
2
1
0
4
3
2
1
0
16
17
18
27
28
CONTROLLING
ENVIRONMENT, SUCH AS
OPERATING A FAN,
THERMOSTAT, OR TV
4
3
2
1
0
29
COMMUNICATING WITH
FAMILY OR FRIENDS
4
3
2
1
0
30. FOR ANY ACTIVITY WHICH YOU MARKED 3 OR LOWER, PLEASE EXPLAIN
31. IN GENERAL, HOW WOULD YOU RATE YOUR OVERALL LEVEL OF INDEPENDENCE?
VERY HIGH
HIGH
LOW
VERY LOW
MODERATE
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)
VA FORM 28-0791, XXX XXXX
35. HOW MUCH, HOW OFTEN, AND WHAT SUBSTANCE (ALCOHOL AND/OR DRUGS) DO YOU USE?
36. WHERE DO YOU CURRENTLY LIVE?
PRIVATE HOME
OWN
RENT
APARTMENT
PART III - HOUSING
HALF-WAY HOUSE
VA DOMICILIARY
HOMELESS SHELTER
OTHER (Please explain)
37. WHO LIVES WITH YOU?
LIVE ALONE
LIVE WITH SPOUSE
RELATIVES
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 SPIRITUAL 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?
43. DO YOU HAVE ANY PROBLEMS GETTING ALONG WITH OTHER PEOPLE?
NO
YES
(If "Yes," please explain)
VA FORM 28-0791, XXX XXXX
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. 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
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, 58VA21/22/28, Compensation, Pension, Education, and Vocational Rehabilitation and Employment 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.
VA FORM 28-0791, XXX XXXX
| File Type | application/pdf |
| File Title | Preliminary Independent Living (IL) Assessment |
| Subject | Independent, Living, Assessment |
| Author | N. KESSINGER |
| File Modified | 2015-01-14 |
| File Created | 2015-01-14 |