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1、KIPBSImpactScale(Rev.1-18-08)KIPBSRater:____________________________________________Date:_____________________KIPBSFacilitator:_______________________________CaseName:________________________Step1.Readtheassessment,intervention,andfollowupplan(s)Step2.LookatthecompletedC
2、ontextualFit,QualityofLife,andPCPSatisfactionsurveysStep3.CompletetheKIPBSPlanQualityEvaluationWorksheet(attached)Step4.CompletetheKIPBSPlanQualityEvaluationSummary(attached)Step5.CompletetheKIPBSImpactScale(below)KIPBSImpactScaleBasedonyourreadingoftheassessment,interve
3、ntion,andfollowupplan(s);takingintoconsiderationempiricaldataandanecdotalinformation,aswellasContextualFit,QualityofLife,andPCPSatisfactionsurveyinformation;pleaseratetheimpactoftheplanoneachofthefollowing:Usethefollowingscale:1=Overall,theplanhadaNEGATIVEimpact,2=Overal
4、l,theplanhadNOimpact,3=Overall,theplanhadaPOSITIVEimpact1.Impactoftheplanontheperson’soverallproblembehaviors1232.Impactoftheplanontheperson’soverallappropriate/adaptivebehaviors1233.Impactoftheplanontheperson’squalityoflife1234.Impactoftheplanontheteam’stime,resources,a
5、ndneeds(i.e.contextualfit)1235.Impactoftheplanontheteam’ssatisfactionwiththeresults1236.Impactoftheplanonthecaregivers’satisfactionwiththeresults1237.Impactoftheplanonthecaregivers’qualityoflife123E:file-serverfs_tmpdownload57381a2f9173715946b8acde9bbd4280.docKIPBSPl
6、anQualityEvaluationSummary(Rev.1-18-08)KIPBSRater:____________________________________________Date:_____________________KIPBSFacilitator:_______________________________CaseName:________________________CompletetheKIPBSPlanQualityEvaluationSummaryafterreadingtheassessment,
7、intervention,andfollowupplan(s);aftergoingthroughtheinformationinthecompletedsurveysattachedtotheplan(s);andaftercompletingtheKIPBSPlanQualityEvaluationWorksheet(attached)QuestionAnswer1.Howmanyproblembehaviorsdidtheplantarget?2.Inyouropinion,howmanyofthesetargetedproble
8、mbehaviorswouldbeconsidered“significant”problembehaviors(i.e.dangerousbehaviors,behaviorsthatmaycontrib
