BAS-Behov av stöd 1001191

Behov av stöd och omfattning – en intervjuguide

Informera sökanden om att denna intervjuguide består av tre delar:

Del I Sökandens funktionsnedsättning, boende, sysselsättning och nuvarande stöd från samhället.

Del II Sökandens behov av stöd samt omfattning av stödet.

Del III Övrig information.

Prövningsversion 1 2010-01-19

Lennart Jansson IMS/SocialstyrelsenHelene Wirandi Socialstyrelsen

Kärstin Eriksson-Blick FörsäkringskassanRose-Marie Nylander IMS/Socialstyrelsen

Sökanden

Förnamn: _______________________________________________________________________________

Efternamn:______________________________________________________________________________

Personnummer: _________________________________

Bostadsadress: ________________________________________________________________________

E-post:______________________________________________________

Telefonnummer: ________________________________

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Intervju utförd av (namn): ___________________________________________________________

Telefon: ___________________E-post:______________________________________________

Datum för intervju (ååmmdd): ______ - ______ - _____

Typ av ansökan: o Ny ansökan Ankomst datum:______________o Ansökan om fler timmaro 2-årsomprövningo Anmälan

Plats för intervju: o Hembesöko Kontoreto Annan plats, vilken? ______________________________________

Närvarande personer vid intervjun:

o Sökanden o Ställföreträdande (vårdnadshavare, god man, förvaltare) o Fullmakt:

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o Annan person, vem?

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Del ISökandens funktionsnedsättning, boende, sysselsättning och nuvarande stöd från samhället

1. Kan Du beskriva din funktionsnedsättning och hur den yttrar sig? (Sammanfatta den sökandes beskrivning av funktionsnedsättningen och vilka svårigheter den medför. Ange även om det är någon förändring sedan tidigare ansökan).

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2. Utred om någon funktionsnedsättning är tillfällig?

Anteckningar:_____________________________________________________________________________________________________

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3. Utred om behovet av stöd varierar över tid? (Ex sjukdom som går i skov)Anteckningar:_____________________________________________________________________________________________________

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4. Utred sökandens dygnsvila? kl _______ - _______ kl _______ - _______

kl_______ - _______ kl _______ - _______

5. Utred om det finns någon tid på dygnet då den sökande inte behöver stöd?Anteckningar:_____________________________________________________________________________________________________

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6. Utred om sökanden någon gång under dygnet behöver hjälp av mer än 1 person (Dubbelassistans). Ange vid vilka aktiviteter.

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7. Hur bor du?

O Ordinärt boende: __________________________________________________________________________

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O Bostad med särskild service O Enligt SOL O Enligt LSS

Typ av bostad: ___________________________________________________

8. Finns det anpassningar och hjälpmedel i bostaden?

O Nej O Ja

Om ja, vilken/vilka? ________________________________________________________________________________

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9. Vistas du regelbundet på andra ställen (t ex fritidshus eller släktings hem)?

O Nej O Ja

10. Finns där anpassningar och hjälpmedel?

O Nej O Ja

Om ja, vilken/vilka? ________________________________________________________________________________

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11. Bor du ensam eller tillsammans med någon annan vuxen?

O Bor ensamO Bor tillsammans med make/maka/sambo/partnerO Bor tillsammans med förälder/föräldrarO Bor tillsammans med annan vuxen person

12. Har du hemmaboende barn yngre än 18 år? O Nej O Ja, ålder: ________________________

13. Har du umgängesrätt med barn under 18 år? O Nej O Ja

Om Ja, omfattning: ______________________

Ålder: _____________________________

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14. Vad gör du på dagarna? Har du arbete/studier/annan dagligt återkommande sysselsättning? O Nej O Ja

(Behov av stöd att utföra arbetet, se fråga 20, sid 79) (Behov av stöd att genomföra studier, se fråga 21, sid 81)

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O Lönearbete Omfattning, tider: ________________________________________________________

O Eget företagResor: ________________________________________________________________

O Daglig verksamhet Omfattning, tider: ________________________________________________________

Resor: ________________________________________________________________

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Finns anpassningar och hjälpmedel (miljö/personal) i verksamheten?(Utred även särskilda skäl, se även sid 6).

O Nej O Ja, vilken/vilka: _______________________________________________

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O Studier på grundskola/gymnasium/folkhögskola/högskolaO Studier i särskola

Omfattning, tider: ________________________________________________________

Resor: ________________________________________________________________

Finns anpassningar och hjälpmedel (miljö/personal) i studiemiljö? (Utred även särskilda skäl, se även sid 6).


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O Lov/skolfria dagarOmfattning, tider: ________________________________________________________

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Tillsyn:_______________________________________________________________

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O Fritids (Skolbarnsomsorg, korttidstillsyn)O Förskoleverksamhet


Resor: ________________________________________________________________

Finns anpassningar och hjälpmedel (miljö/personal)?(Utred även om behoven är tillgodosedda av annan t ex korttidstillsyn enl LSS)


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O Annan sysselsättning, vilken? ______________________________________________________________


Resor: ________________________________________________________________

Finns anpassningar och hjälpmedel?


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O Särskilda skäl:_________________________________________________________________

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Särskilda skäl (fortsättning)

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Aktuellt samhällsstöd

Utred den sökandes aktuella hjälp från kommunen, landstinget eller Försäkringskassan.

16. Har du personlig assistans idag?

O Nej O Ja

O Enligt LSS O Enligt LASS

Omfattning: __________________________Anordnare: ____________________________________________________

Anteckningar: ___________________________________________________________________________________________________

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17. Utred om den sökande har någon annan ersättning från Försäkringskassan pga sin funktionsnedsättning.

Typ av ersättning och storleken på denna__________________________________________________________________

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18. Har du något stöd från kommunen?

O Korttidsvistelse Omfattning: ______________________________________________________

O Hemtjänst/boendestöd Omfattning: ______________________________________________________

O Färdtjänst/skolskjuts Omfattning: ______________________________________________________

O Annan insats Omfattning: ______________________________________________________

Vilken:____________________________________________________________________________

Anteckningar: ___________________________________________________________________________________________________

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19. Har du något stöd från landstinget?

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Personlig vård

01. Klarar du av att på egen hand tvätta och torka dig själv? (Att tvätta och torka hela eller delar av kroppen, t ex att bada, duscha, tvätta händer, fötter, ansikte och hår och att torka sig)

O Ja gå till fråga 02

O Nej forstätt nedan

Del IIInformera om att Del II är uppdelad i 9 områden som berör den sökandes dagliga liv: 1) Personlig vård, 2) Hemliv, 3) Förflyttning, 4) Kommunikation, 5) Arbete, 6) Studier, 7) Samhällsgemenskap, socialt- och medborgerligt liv, 8) Att vara förälder och 9) Ingående kunskap.

Det första avsnittet handlar om personlig vård, d v s att tvätta sig och torka sig, kroppsvård, att sköta toalettbehov, att klä sig, att äta och dricka samt att sköta sin egen hälsa.

Beskriv ditt behov av hjälp:

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01a. Tvätta och torka delar av kroppen (Ex att rengöra och torka händer, ansikte, fötter och hår)

Utredarens bedömning:

01a3. Är sökandens beskrivning av sitt hjälpbehov rimlig? O Ja O Nej

01a4. Är sökandens uppskattning av tidsåtgång rimlig? O Ja O Nej, för hög O Nej, för låg

01a5. Är aktiviteten ett grundläggande behov? O Ja O Delvis O Nej

01a6. Berättigar aktiviteten till assistans? O Ja O Delvis O Nej (Föräldrars ansvar, make/makas ansvar)

01a7. Slutlig bedömning av tidsåtgång (om annan än ovanstående):

Grundläggande behov: ________ tim/vecka Andra personliga behov: ________ tim/vecka

Dagtid06-19

Kväll19 - 22

Natt22 - 06

01a1. Tvätta och torka delar av kroppen

DubbelassistansSökandens uppfattning av tidsåtgång:

Per dygn:

Per vecka:01a2. Tvätta och torka delar av kroppen

Antal Omfattning Antal AntalOmfattning Omfattning Omfattning

Anteckningar/Kommentarer

01a3. Är sökandens beskrivning av hjälpbehovet rimlig?

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01a4. Är sökandens uppskattning av tidsåtgång rimlig?

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01a5. Är aktiviteten ett grundläggande behov?

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01a6. Berättigar aktiviteten till assistans?

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01a7. Slutlig bedömning av tidsåtgång.

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01b. Tvätta och torka hela kroppen (Att tvätta och torka hela kroppen inkl hår, tex bad eller dusch)

Dagtid06-19

Kväll19 - 22

Natt22 - 06

01b1. Tvätta och torka hela kroppen


Per dygn:

Per vecka:01b2. Tvätta och torka hela kroppen



01b3. Är sökandens beskrivning av sitt hjälpbehov rimlig? O Ja O Nej

01b4. Är sökandens uppskattning av tidsåtgång rimlig? O Ja O Nej, för hög O Nej, för låg

01b5. Är aktiviteten ett grundläggande behov? O Ja O Delvis O Nej

01b6. Berättigar aktiviteten till assistans? O Ja O Delvis O Nej (Föräldrars ansvar, make/makas ansvar)

01b7. Slutlig bedömning av tidsåtgång (om annan än ovanstående):



01b3. Är sökandens beskrivning av hjälpbehovet rimlig?

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01b4. Är sökandens uppskattning av tidsåtgång rimlig?

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01b5. Är aktiviteten ett grundläggande behov?

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01b6. Berättigar aktiviteten till assistans?

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01b7. Slutlig bedömning av tidsåtgång.

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02a. Hudvård (Att sköta vävnad och fukt i sin hud såsom att ta bort valkar och liktornar, att använd fuktbevarande

lotioner/salvor eller kosmetika)

Dagtid06-19

Kväll19 - 22

Natt22 - 06

02a1. Hudvård

Dubbelassistans

Sökandens uppfattning av tidsåtgång:

Per dygn:

Per vecka:02a2. Hudvård


02. Klarar du av att på egen hand sköta din kroppsvård? (Att vårda de delar av kroppen som kräver mer än att tvätta och torka sig såsom hud, ansikte, tänder, hårbotten, naglar och könsorgan. Innefattar hudvård, tandvård, hårvård, att sköta naglar samt annan kroppsvård)


O Nej fortsätt nedan










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02b. Tandvård (Att borsta tänderna, rengöra med tandtråd, ta hand om tandproteser och tandbryggor)

Dagtid06-19

Kväll19 - 22

Natt22 - 06

02b1. Tandvård

Dubbelassistans


Per dygn:

Per vecka:02b2 Tandvård











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02c. Hårvård (Att sköta sitt hår på huvudet och ansiktet tex att kamma sig, ordna frisyr, raka sig och klippa sig)

Dagtid06-19

Kväll19 - 22

Natt22 - 06

02c1. Hårvård

Dubbelassistans


Per dygn:

Per vecka:02c2 Hårvård



02c3. Är sökandens beskrivning av sitt hjälpbehov rimlig? O Ja O Nej

02c4. Är sökandens uppskattning av tidsåtgång rimlig? O Ja O Nej, för hög O Nej, för låg

02c5. Är aktiviteten ett grundläggande behov? O Ja O Delvis O Nej

02c6. Berättigar aktiviteten till assistans? O Ja O Delvis O Nej (Föräldrars ansvar, make/makas ansvar)

02c7. Slutlig bedömning av tidsåtgång (om annan än ovanstående):



02c3. Är sökandens beskrivning av hjälpbehovet rimlig?

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02c4. Är sökandens uppskattning av tidsåtgång rimlig?

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02c5. Är aktiviteten ett grundläggande behov?

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02c6. Berättigar aktiviteten till assistans?

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02c7. Slutlig bedömning av tidsåtgång.

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02d. Nagelvård (Att rengöra, klippa eller lackera naglarna på händer och fötter)

Dagtid06-19

Kväll19 - 22

Natt22 - 06

02d1. Nagelvård

Dubbelassistans


Per dygn:

Per vecka:02d2 Nagelvård



02d3. Är sökandens beskrivning av sitt hjälpbehov rimlig? O Ja O Nej

02d4. Är sökandens uppskattning av tidsåtgång rimlig? O Ja O Nej, för hög O Nej, för låg

02d5. Är aktiviteten ett grundläggande behov? O Ja O Delvis O Nej

02d6. Berättigar aktiviteten till assistans? O Ja O Delvis O Nej (Föräldrars ansvar, make/makas ansvar)

02d7. Slutlig bedömning av tidsåtgång (om annan än ovanstående):



02d3. Är sökandens beskrivning av hjälpbehovet rimlig?

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02d4. Är sökandens uppskattning av tidsåtgång rimlig?

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02d5. Är aktiviteten ett grundläggande behov?

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02d6. Berättigar aktiviteten till assistans?

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02d7. Slutlig bedömning av tidsåtgång.

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03. Klarar du av att på egen hand sköta toalettbehov? (Förflyttning till toalettstol, förflyttning på och av toalettstol, hantering av kläder före och efter toalettbesök, rengöring och torkning. Tänk även på kateter, blöja, lavemang etc)



03a. Sköta toalettbehov


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Dagtid06-19

Kväll19 - 22

Natt22 - 06

03a1. Sköta toalettbehov

Dubbelassistans


Per dygn:











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04. Klarar du av att på egen hand klä på och av dig? (Klä på och av sig, ta fram och lägga undan kläder och skor, ta av och på ytterkläder)




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Dagtid06-19

Kväll19 - 22

Natt22 - 06

04a1. Klä på och av sig

Dubbelassistans


Per dygn:

Per vecka:04a2. Klä på och av sig


04a. Klä på och av sig










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Dagtid06-19

Kväll19 - 22

Natt22 - 06

04b1. Ta fram och lägga undan kläder och skor

Dubbelassistans


Per dygn:

Per vecka:04b2. Ta fram och lägga undan kläder och skor


04b. Ta fram och lägga undan kläder och skor










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Dagtid06-19

Kväll19 - 22

Natt22 - 06

04c1. Ta av och på ytterkläder

Dubbelassistans


Per dygn:

Per vecka:04c2. Ta av och på ytterkläder


04c. Ta av och på ytterkläder










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29

05. Klarar du av att på egen hand sköta din hälsa? (Att tillförsäkra sig fysisk bekvämlighet, hälsa och fysiskt och psykiskt välbefinnande såsom att upprätthålla en balanserad diet, lämplig nivå av fysisk aktivitet, hålla sig varm eller kall, undvika hälsorisker, ha säkra sexualvanor, bli vaccinerad och genomgå regelbundna hälsokontroller)


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Dagtid06-19

Kväll19 - 22

Natt22 - 06

05a1. Sköta din hälsa

Dubbelassistans


Per dygn:

Per vecka:05a2. Sköta din hälsa


05a. Sköta din hälsa












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31

06. Klarar du av att på egen hand besöka vårdinrättningar och liknande?(Ex sjukhus, vårdcentral, hjälpmedelscentral, sjukgymnastik. Det gäller regelbundna, planerade, förväntade besök)


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Dagtid06-19

Kväll19 - 22

Natt22 - 06

06a1. Besöka vårdinrättningar eller liknande

Dubbelassistans


Per dygn:

Per vecka:06a2. Besöka vårdinrättningar eller liknande


06a. Besöka vårdinrättningar eller liknande

06a3. Besöka vårdinrättningar eller liknande

Per månad:












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33

07. Klarar du av att på egen hand äta och dricka mat och dryck? (Använda matbestick/föra mat och dryck till munnen, dela maten i bitar, fram- och bortplockning, matning via sond. I begreppet ”kan äta själv” avses inte bara att kunna föra maten till munnen. Det kan finnas andra speciella svårigheter som gör att det inte går att lämna personen med att själv föra maten till munnen)


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Dagtid06-19

Kväll19 - 22

Natt22 - 06

08a1. Äta frukost

Dubbelassistans


Per dygn:


08a. Äta frukost












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Dagtid06-19

Kväll19 - 22

Natt22 - 06

08b1. Dela maten i bitar, fram- och bortplockning i samband med frukost

Dubbelassistans


Per dygn:


08b. Dela maten i bitar, fram- och bortplockning i samband med frukost










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Dagtid06-19

Kväll19 - 22

Natt22 - 06

09a1. Äta lunch

Dubbelassistans


Per dygn:


09a. Äta lunch










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Dagtid06-19

Kväll19 - 22

Natt22 - 06

09b1. Dela mat i bitar, fram. och bortplockning i samband med lunch

Dubbelassistans


Per dygn:


09b. Dela maten i bitar, fram- och bortplockning i samband med lunch










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Dagtid06-19

Kväll19 - 22

Natt22 - 06

10a1. Äta middag

Dubbelassistans


Per dygn:


10a. Äta middag










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Dagtid06-19

Kväll19 - 22

Natt22 - 06

10b1. Dela maten i bitar, fram- och bortplockning i samband med middag

Dubbelassistans


Per dygn:


10b. Dela maten i bitar, fram- och bortplockning i samband med middag










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Dagtid06-19

Kväll19 - 22

Natt22 - 06

11a1. Äta mellanmål

Dubbelassistans


Per dygn:


11a. Äta mellanmål










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Dagtid06-19

Kväll19 - 22

Natt22 - 06

11b1. Dela maten i bitar, fram- och plockning i samband med mellanmål

Dubbelassistans


Per dygn:


11b. Dela maten i bitar, fram- och bortplockning i samband med mellanmål










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49

12. Är det något annat du behöver hjälp med när det gäller personlig vård?


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12a. Övrigt personlig vård

O Nej gå till fråga 13

O Ja fortsätt nedan

Dagtid06-19

Kväll19 - 22

Natt22 - 06

12a1. Övrigt personlig vård

Dubbelassistans


Per dygn:

Per vecka:12a2. Övrigt personlig vård


12a3. Övrigt personlig vård Per månad:










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12a7 Berättigar aktiviteten till assistans?

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Hemliv

13. Klarar du av att på egen hand laga mat? (Planera och organisera och laga enklare måltider, planera, organisera och laga sammansatta måltider,

städa upp efter matlagning).



Detta avsnitt handlar om matlagning, att göra inköp och ärenden, hushållsarbete.


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13a. Planera, organisera och laga enklare måltider (Frukost, mellanmål, värma färdigmat)

Dagtid06-19

Kväll19 - 22

Natt22 - 06

13a1. Planera, organisera och laga enklare måltider


Per dygn:

Per vecka:13a2. Planera, organisera och laga enklare måltider











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13b. Planera, organisera och laga sammansatta måltider

Dagtid06-19

Kväll19 - 22

Natt22 - 06

13b1. Planera, organisera och laga sammansatat måltider


Per dygn:

Per vecka:13b2. Planera, organisera och laga sammansatta måltider











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13b6 Berättigar aktiviteten till assistans?

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13c. Städa upp efter matlagning

Dagtid06-19

Kväll19 - 22

Natt22 - 06

13c1. Städa upp efter matlagning


Per dygn:

Per vecka:13c2. Städa upp efter matlagning











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14. Klarar du av att på egen hand göra inköp och andra ärenden? (Planera inköp, ta dig till och från inköpsstället, plocka ihop varor, frakta hem varor, plocka in varorna,

besöka bank, post, apotek och betala räkningar)




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14a. Planera, genomföra inköp och andra ärenden

Dagtid06-19

Kväll19 - 22

Natt22 - 06

14a1. Planera, genomföra inköp och andra ärenden

Dubbelassistans


Per dygn:

Per vecka:14a2. Planera, genomföra inköp och andra ärenden


14a3. Planera, genomföra inköp och andra ärenden

Per månad:










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15. Klarar du av att på egen hand att sköta hushållsarbetet? (Städa hemmet, tvätta och torka kläder, sköta växter, ta hand om husdjur, underhålla hjälpmedel, underhålla fordon)




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15a. Städa hemmet (Städa upp och damma, sopa, skura, torka golv, tvätta fönster och väggar, rengöra badrum, toaletter och hemmet möbler, bädda sängen, samla ihop skräp, sopor och avfall för att kasta)

Dagtid06-19

Kväll19 - 22

Natt22 - 06

15a1. Städa hemmet

Dubbelassistans


Per dygn:

Per vecka:15a2. Städa hemmet


15a3. Städa hemmet Per månad:










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61

15b. Tvätta och torka kläder och andra textilier, enklare klädvård (Samla ihop, tvätta, torka, stryka, vika och plocka in i lådor/skåp. Enklare klädvård såsom att laga och ändra)

Dagtid06-19

Kväll19 - 22

Natt22 - 06

15b1. Tvätta och torka kläder och andra textilier, enklare klädvård

Dubbelassistans


Per dygn:

Per vecka:15b2. Tvätta och torka kläder och andra textilier, enklare klädvård


15b3. Tvätta och torka kläder och andra textilier, enklare klädvård

Per månad:


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15b7 Berättigar aktiviteten till assistans?

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15c. Sköta växter, ta hand om husdjur

Dagtid06-19

Kväll19 - 22

Natt22 - 06

15c1. Sköta växter, ta hand om husdjur

Dubbelassistans


Per dygn:

Per vecka:15c2. Sköta växter, ta hand om husdjur


15c3. Sköta växter, ta hand om husdjur

Per månad:










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15d. Underhålla hjälpmedel och fordon (Reparera och ta hand om hjälpmedel, besöka hjälpmedelscentralen. Städa, tvätta och tanka fordon)

Dagtid06-19

Kväll19 - 22

Natt22 - 06

15d1. Underhålla hjälpmedel och fordon

Dubbelassistans


Per dygn:

Per vecka:15d2. Underhålla hjälpmedel och fordon


15d3. Underhålla hjälpmedel och fordon

Per månad:


15d4. Är sökandens beskrivning av sitt hjälpbehov rimlig? O Ja O Nej

15d5. Är sökandens uppskattning av tidsåtgång rimlig? O Ja O Nej, för hög O Nej, för låg

15d6. Är aktiviteten ett grundläggande behov? O Ja O Delvis O Nej

15d7. Berättigar aktiviteten till assistans? O Ja O Delvis O Nej (Föräldrars ansvar, make/makas ansvar)

15d8. Slutlig bedömning av tidsåtgång (om annan än ovanstående):



15d4. Är sökandens beskrivning av hjälpbehovet rimlig?

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15d5. Är sökandens uppskattning av tidsåtgång rimlig?

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15d6. Är aktiviteten ett grundläggande behov?

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15d7. Berättigar aktiviteten till assistans?

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15d8. Slutlig bedömning av tidsåtgång.

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67

16. Är det något annat du behöver hjälp med när det gäller hemlivet?


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16a. Övrigt hemlivet



Dagtid06-19

Kväll19 - 22

Natt22 - 06

16a1. Övrigt hemlivet

Dubbelassistans

Sökandens uppfatttning av tidsåtgång:

Per dygn:

Per vecka:16a2. Övrigt hemlivet


16a3. Övrigt hemlivet Per månad:










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Förflyttning

17. Klarar du av att på egen hand ändra kroppsställning, förflytta dig i bostaden eller förflytta föremål? (Här ingår ändra läge i sängen, sätta dig upp från liggande, böja dig framåt/åt sidan, ställa dig upp från sittande,

förflyttning i bostaden samt förflytta föremål).



Detta avsnitt handlar om att röra sig på olika sätt t ex genom att ändra kroppsställning, förflyttasig i bostaden eller att förflytta föremål. Det handlar om förflyttning som inte sker i samband med aktiviteter som behandlas i övriga avsnitt.


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17a. Ändra kroppsställning (Ändra läge i sängen, sätta sig upp från liggande, böja sig framåt/åt sidan, ställa sig upp från sittande)

Dagtid06-19

Kväll19 - 22

Natt22 - 06

17a1. Ändra kroppsställning


Per dygn:

Per vecka:17a2 Ändra kroppsställning











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17b. Förflyttning i bostaden (Ex ta dig ur/i sängen/stol eller mellan stolar, förflytta dig mellan olika rum i bostaden)

Dagtid06-19

Kväll19 - 22

Natt22 - 06

17b1. Förflyttning i bostaden

Dubbelassistans


Per dygn:

Per vecka:17b2 Förflyttning i bostaden











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17c. Förflytta föremål/handräckning (Lyfta och bära föremål ex ett glas. Gripa/plocka små föremål ex mynt, penna. Bära föremål från en plats till en annan)

Dagtid06-19

Kväll19 - 22

Natt22 - 06

17c1. Förflytta föremål/handräckning

Dubbelassistans


Per dygn:

Per vecka:17c2 Förflytta föremål/handräckning











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18. Är det något annat du behöver hjälp med när det gäller förflyttning?


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18a. Övrig förflyttning



Dagtid06-19

Kväll19 - 22

Natt22 - 06

18a1. Övrig förflyttning

Dubbelassistans


Per dygn:

Per vecka:18a2. Övrig förflyttning


18a3. Övrig förflyttning Per månad:










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Kommunikation

19. Klarar du av att på egen hand kommunicera med andra? (Uttrycka dig och förstå vad andra uttrycker, använda teckenspråk, bliss etc. Det är inte alltid sökanden kan svara själv

på denna fråga, ställe den då till god man, förälder eller annan ställföreträdande som är med under utredningen)



Detta avsnitt handlar om att kommunicera med andra


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19a. Beskriv dina svårigheter att kommunicera med andra om/när det krävs en tredje person för att du ska kunna göra dig förstådd eller förstå.

Dagtid06-19

Kväll19 - 22

Natt22 - 06

19a1. Kommunikation


Per dygn:

Per vecka:19a2 Kommunikation











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Arbete

20. Klarar du av att på egen hand utföra ditt arbete?



Detta avsnitt besvaras endast om den sökande arbetar.


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79

20a. Utföra arbete

Dagtid06-19

Kväll19 - 22

Natt22 - 06

20a1. Utföra arbete

Dubbelassistans

Sökandens upffatning av tidsåtgång:

Per dygn:

Per vecka:20a2. Utföra arbete


20a3. Utföra arbete Per månad:










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Studier

21. Klarar du av att på egen hand genomföra dina studier?



Detta avsnitt besvaras endast om den sökande studerar.


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21a. Genomföra studier

Dagtid06-19

Kväll19 - 22

Natt22 - 06

21a1. Genomföra studier

Dubbelassistans


Per dygn:

Per vecka:21a2. Genomföra studier


21a3. Genomföra studier Per månad:










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Samhällsgemenskap, socialt och medborgerligt liv

22. Klarar du av att på egen hand delta i samhällsaktiviteter?



Här handlar det om den praktiska hjälpen/stödet för att den sökande ska kunna delta i olika samhällsaktiviteter. Förflyttning skall medräknas inom respektive aktivitet. Tänk på att inte ta upp behovet av samma aktivitet två eller flera gånger.


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22a. Delta i samhällsaktiviteter(Ex delta i organisationer/föreningar, utöva religion och andlighet, delta i politiskt liv)

Dagtid06-19

Kväll19 - 22

Natt22 - 06

22a1. Delta i samhällsaktiviteter

Dubbelassistans


Per dygn:

Per vecka:22a2. Delta i samhällsaktiviteter


22a3. Delta i samhällsaktiviteter Per månad:










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23. Klarar du av att på egen hand utöva fritidsaktiviteter?




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23a. Utöva fritidsaktiviteter(Ex delta i eller utöva lek-, spel- eller sportaktiviteter, träning, kulturliv, hobbies, läsning, musikintressen,

semesterresor, umgås med vänner/familj/släkt)

Dagtid06-19

Kväll19 - 22

Natt22 - 06

23a1. Utöva fritidsaktiviteter

Dubbelassistans


Per dygn:

Per vecka:23a2. Utöva fritidsaktiviteter


23a3. Utöva fritidsaktiviteter Per månad:










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Att vara förälder

24. Har du några svårigheter att utöva ditt föräldraskap?


O Ja forstätt nedan

Detta avsnitt besvaras endast om den sökande är förälder till barn under 19 år


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24a. Att vara förälder

Dagtid06-19

Kväll19 - 22

Natt22 - 06

24a1. Att vara förälder

Dubbelassistans


Per dygn:

Per vecka:24a2. Att vara förälder


24a3. Att vara förälder Per månad:










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25a. Utred vad det är för särskild kunskap som krävs

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25b. Utred i vilka situationer som denna kunskap/kompetens krävs

Ingående kunskap

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Del III Övrig information

26. Finns det behov av stöd inom något annat område som inte berörts?

(Instruktion: Gå tillbaka i intervjuguiden och reflektera över om det är några svårigheter som inte berörts).

O Nej O Ja

Anteckningar: _____________________________________________________________________________________________________

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27. Finns det behov av jour eller beredskap?

O Nej O Ja

Anteckningar: _____________________________________________________________________________________________________

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28. Är sjukvårdande insatser utredda? (Även särskilda skäl vid sjukhusvistelse)

O Nej O Ja

Anteckningar: _____________________________________________________________________________________________________

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29. Finns det idag något avtal med någon assistansanordnare?

O Nej O Ja, vilken: _____________________________________________________________

Anteckningar: _____________________________________________________________________________________________________

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Documents

BAS-Behov av stöd 1001191