Form Name (Form Number) - Illinois Department of Human Services

State of Illinois
Department of Human Services Division of Developmental Disabilities
DIRECT SUPPORT PERSON TRAINING PROGRAM
INTERVENTIONAL COMPETENCIES EVALUATION FORM
For Agencies Seeking Approval of OJTs/CBTAs
On-the-Job Training/Competency Based
Training Assessments
Agencies that modify DHS approved OJT/CBTAs or agencies that develop their own OJT/CBTA's are required to complete this form.
Please check one:
The Agency is modifying one or more of the DHS approved OJT/CBTA's to meet the 80-hour OJT/CBTA training requirement.
The Agency is using its agency-developed OJT/CBTAs to meet the entire 80-hour OJT/CBTA training requirement.
Directions:
1.
2.
3.
4.
The following table includes the listing of interventional competencies required for Direct Support Person Training.
Find the OJT/CBTA where each competency is addressed in your on-the-job training materials.
List that OJT/CBTA number in the column to the right of the competency.
Return this completed form and all agency developed or DHS modified OJT/CBTAs to the Division of Developmental
Disabilities:
Department of Human Services
Division of Developmental Disabilities
319 E. Madison, Suite 4J
Springfield, IL 62701
Fax: (217) 782-9444
Email address: [email protected]
Please Complete Agency Contact Information
Form Prepared By
Agency Name
Fax Number
Telephone Number
E-mail
I certify that this agency will comply fully with the OJT/CBTA program it proposes.
Signature of Executive Director
Date
DHS Office Use Only
DHS Evaluator
Telephone Number
Fax Number
Date of Initial Evaluation
Date of Second Evaluation
Date Approved
IL462-1284 (R-4-13) Direct Support Person (DSP) Training Program Interventional
Competencies Evaluation Form
Printed by Authority of the State of Illinois -0- Copies
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State of Illinois
Department of Human Services Division of Developmental Disabilities
DIRECT SUPPORT PERSON TRAINING PROGRAM
INTERVENTIONAL COMPETENCIES EVALUATION FORM
Introduction to Developmental Disabilities
The DSP:
OJT/CBTA
Number(s)
DHS Use
Accepted
Information
Requested
1. creates opportunities for the individual to speak
on his/her own behalf in a variety of situations.
2. provides information needed to complete
assessments that are relevant to the individual's
goals, interests and preferences and that are
consistent with relevant professional practice.
3. names and defines life skill areas and
demonstrates observable skills and tasks.
4. defines developmental disabilities and lists
associated characteristics.
5. follows established directions and procedures.
6. demonstrates understanding of informational
releases.
7. uses people first language.
Human Rights
The DSP:
OJT/CBTA
Number(s)
DHS Use
Accepted
Information
Requested
1. contributes to the normalized living environment.
2. utilizes person-centered language and concepts.
3. communicates effectively in verbal and written
form.
4. demonstrates cultural competency in the
planning process.
5. intervenes or identifies advocacy issues.
IL462-1284 (R-4-13) Direct Support Person (DSP) Training Program Interventional
Competencies Evaluation Form
Printed by Authority of the State of Illinois -0- Copies
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State of Illinois
Department of Human Services Division of Developmental Disabilities
DIRECT SUPPORT PERSON TRAINING PROGRAM
INTERVENTIONAL COMPETENCIES EVALUATION FORM
Human Rights
The DSP:
DHS Use
OJT/CBTA
Number(s)
Accepted
Information
Requested
6. obtains information from the individual.
7. demonstrates an ability to build rapport.
8. offers opportunities for choice.
9. recognizes human rights violations.
10. identifies available community resources.
11. educates individuals in choice making
and their potential outcomes.
12. follows established directions and
procedures.
13. assists in individual self-advocacy efforts.
14. protects rights, privacy and confidentiality.
15. respects personal property.
Abuse and Neglect, Prevention, Recognition
and Intervention
The DSP:
DHS Use
OJT/CBTA
Number(s)
Accepted
Information
Requested
1. participates in producing a healthy,
engaging environment.
2. recognizes the forms of abuse, neglect and
financial exploitation.
IL462-1284 (R-4-13) Direct Support Person (DSP) Training Program Interventional
Competencies Evaluation Form
Printed by Authority of the State of Illinois -0- Copies
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State of Illinois
Department of Human Services Division of Developmental Disabilities
DIRECT SUPPORT PERSON TRAINING PROGRAM
INTERVENTIONAL COMPETENCIES EVALUATION FORM
Abuse and Neglect, Prevention, Recognition
and Intervention
The DSP:
DHS Use
OJT/CBTA
Number(s)
Accepted
Information
Requested
3. follows rules/procedures for preventing,
identifying and reporting abuse, neglect and
financial exploitation.
4. develops strategies for preventing abuse,
neglect and financial exploitation.
5. contributes to creating a supportive
environment.
Human Interaction and Communication
The DSP:
OJT/CBTA
Number(s)
DHS Use
Accepted
Information
Requested
1. is respectful.
2. actively engages in a non-directive manner
with individuals.
3. recognizes speech deficiencies.
4. demonstrates various communication modes
and styles.
5. demonstrates effective use of assistive
technology.
6. demonstrates active listening skills.
7. recognizes and demonstrates appropriate
modes of communication with the individual.
8. implements communication programs.
9. documents results of communication programs.
IL462-1284 (R-4-13) Direct Support Person (DSP) Training Program Interventional
Competencies Evaluation Form
Printed by Authority of the State of Illinois -0- Copies
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State of Illinois
Department of Human Services Division of Developmental Disabilities
DIRECT SUPPORT PERSON TRAINING PROGRAM
INTERVENTIONAL COMPETENCIES EVALUATION FORM
DHS Use
Human Interaction and Communication
The DSP:
OJT/CBTA
Number(s)
Accepted
Information
Requested
10. initiates the process for revising the
communication program as needed.
11. establishes rapport.
12. supports choices.
13. demonstrates appropriate transfer of
information from staff to staff.
14. recognizes and provides support during times of
grief.
Service Plan Development and
Implementation
OJT/CBTA
Number(s)
The DSP:
DHS Use
Accepted
Information
Requested
1. actively participates in the development of an
individual's service plan.
2. involves the individual in identifying and
choosing activities and supports and addresses
potential barriers/problems.
3. schedules events and needed supports as
requested.
4. monitors successes in achieving outcomes.
5. serves as a professional and active member of
the IDT/community support team.
6. listens to the individual.
7. respects the appropriate boundaries of the
relationship.
8. communicates effectively with the individual and
the IDT/community support team.
IL462-1284 (R-4-13) Direct Support Person (DSP) Training Program Interventional
Competencies Evaluation Form
Printed by Authority of the State of Illinois -0- Copies
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State of Illinois
Department of Human Services Division of Developmental Disabilities
DIRECT SUPPORT PERSON TRAINING PROGRAM
INTERVENTIONAL COMPETENCIES EVALUATION FORM
Service Plan Development and
Implementation
The DSP:
DHS Use
OJT/CBTA
Number(s)
Accepted
Information
Requested
9. reviews and completes assessments.
10. facilitates choice in the person's life by assisting
in identifying positives and negatives.
11. encourages and develops individual's leisure
interests.
12. assists the individual in obtaining employment completes job applications and prepares the
person for job interviews.
13. completes documentation as required and uses
correction procedure for addressing errors.
14. demonstrates the ability to teach.
15. demonstrates the ability to communicate
effectively with individuals and staff - orally and
in writing.
16. demonstrates organizational and environmental
management skills.
17. assists with the admission, transfer and
discharge of individuals as directed.
18. implements the habilitation plan.
19. participates as directed in social habilitation
(ADL's, therapeutic & leisure time activities,
education, community living adjustment,
behavior development, management and
self-control.)
20. gathers and documents information in an
accurate, objective and unobtrusive manner.
21. documents and communicates identified
strengths, abilities, desires, concerns and needs
of the individual.
22. utilizes age appropriate strategies.
IL462-1284 (R-4-13) Direct Support Person (DSP) Training Program Interventional
Competencies Evaluation Form
Printed by Authority of the State of Illinois -0- Copies
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State of Illinois
Department of Human Services Division of Developmental Disabilities
DIRECT SUPPORT PERSON TRAINING PROGRAM
INTERVENTIONAL COMPETENCIES EVALUATION FORM
Basic Health and Safety
The DSP:
OJT/CBTA
Number(s)
DHS Use
Accepted
Information
Requested
1. implements seizure protocols.
2. recognizes red flags that would be indicators
of medical conditions.
3. notifies appropriate person(s) about emergency
health and safety concerns.
4. accurately determines and records the
individual's vital signs.
5. follows universal precautions and infection
control procedures.
6. demonstrates basic health observation skills.
7. demonstrates proper transfer techniques.
8. demonstrates environmental safety skills.
9. assists with personal hygiene.
10. demonstrates personal care and hygiene skills
and techniques.
11. helps individuals understand their bodily
functions.
12. utilizes proper body mechanics and proper
positioning techniques.
13. implements disaster procedures and assists
individuals as needed.
14. utilizes basic food safety and sanitation
techniques.
15. demonstrates basic nutrition skills.
16. identifies and responds appropriately to safety
hazards.
17. demonstrates techniques required to support
ADL.
18. operates transportation/mobility adaptive
equipment in a safe and appropriate manner.
IL462-1284 (R-4-13) Direct Support Person (DSP) Training Program Interventional
Competencies Evaluation Form
Printed by Authority of the State of Illinois -0- Copies
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