S-4.2, r. 2 - Regulation respecting the classification of services offered by family-type resources and the rates of compensation applicable to each type of service

Schedule Disposition versions

2012-09-01

SCHEDULE I

(s. 2)

IDENTIFICATION OF USER CHARACTERISTICS

Instructions

  1. This questionnaire should be filled out by the
psychosocial intervenor assigned to the user and, if
possible, in collaboration with the family caring 
for the user.

  First provide information on the user on the 
summary sheet (name, date of birth, file number) 
and indicate the user’s main problem.

  Next, indicate the user’s traits by filling out 
section A, "Physical State", and section B, 
"Physical Functioning".

  2. For each of the 10 facets examined, circle the
number of the most appropriate descriptor 
pertaining to the user.

  - Each question must be answered and only 
one response per question must be given.

  - Do not assume that state and functioning
with respect to a particular trait are the same.

  3. Once the 10 descriptors have been pinpointed,
transcribe the circled numbers on the summary sheet
in the space provided and add up the points 
respecting  state, functioning and the overall 
score.

  4. Sign the summary sheet and indicate the date 
on which the evaluation was carried out.

Summary sheet

User:______________________________________________
      Last name  and  first name       
20 ________________________________________________
    Y/M/D Date of birth                File number

  Main problem: Check the box that best describes 
the user.

  Needs social protection: The user is vulnerable
because of a loss of autonomy, or the absence or 
inadequacy of or threats from the family or social
environment, e.g. sexual abuse, neglect, social 
isolation, violence and so on.

  Social maladjustment: The user is suffering from
behavioural or social adjustment problems such as 
alcoholism.

  Mental health problem: The user is suffering from
mental illness, personality disorders or 
psycho-affective disturbances.	

  Physical health problem: Refers to physical 
illness or organic impairments.

  Sensory impairment: The user is suffering from the
loss of or a permanent anomaly in a sensory organ.

  Motor impairment: The user is suffering from the 
loss of or a permanent anomaly in a limb.

  Intellectual impairment: Refers to the simultaneous
presence of a significant intellectual handicap and
problems related to adaptive behaviour.

  Multiple impairments: The user is suffering from 
more than one significant problem.  (Do not select
this item unless it is impossible to pinpoint a 
single main problem.)

Scores transcribed:

SECTION A:                  SECTION B:
PHYSICAL STATE              PHYSICAL
                            FUNCTIONING
Physical state              Physical functioning
Cognitive state             Cognitive functioning
Affective state             Affective functioning
Behavioural state           Behavioural functioning
Relational and social       Relational and social
state                       functioning

Score (State)________ + Score (Functioning) _______
= __________ Overall score

Name of intervener:

Date of the evaluation:

Assessement grid

SECTION A: MEASUREMENT OF PHYSICAL STATE

  "State" refers to the static or structural facet 
of a characteristic, trend, predisposition or a 
given condition.  In the case of physical, 
relational or social traits, a state can be observed
on the basis of the signs or symptoms a person 
displays, and by individual attitudes and behaviour.
As for cognitive, affective and behavioural traits,
a state must be subjected to an overall intellectual 
assessment of the usual quality of the affect or 
type of personality that determines a behavioural 
tendency.

1. PHYSICAL STATE

  Refers to the presence or absence of organic 
(illness), physical (motor) or sensory (hearing or
sight) impairments. An individual’s state of health
refers to his general health in terms of the 
presence or absence of illness or organic 
impairments.  A physical (motor) or sensory 
(hearing or sight) impairment refers to the loss of
or a permanent anomaly in a limb or sensory organ.
Organic impairments or illnesses such as epilepsy, 
multiple sclerosis, cardiovascular problems, 
arthritis, diabetes, cancer and so on are considered 
health problems, regardless of the extent of or 
control over the illness.  Occasional or temporary
indispositions such as the flu or chickenpox should
not be regarded as health problems.

  The user displays:
  
  1   good health and absence of a physical or sensory	
      impairment
  2   good health and presence of physical or sensory
      impairments, or both
  3   health problem(s) and absence of physical or 
      sensory impairment
  4   health problem(s) and presence of physical or 
      sensory impairment(s)
  5   health problem(s) and presence of physical and
      sensory impairment(s)

2. COGNITIVE STATE

  Does not necessarily refer to an assessment of 
intellectual potential through an IQ test but a 
general evaluation of the individual’s intellectual
level.  The assessment entails a comparison with 
the overall population of the same age.

  Assessment of the user’s intelligence:
  
  1   above-average intelligence
  2   average or normal intelligence
  3   bordeline or slow
  4   slight or average impairment
  5   severe or acute impairment
  
3. AFFECTIVE STATE

  Refers to a general assessment of the usual 
quality of the affect or the affective state and 
applies equally to simple or complex states of 
pleasure, neutrality or displeasure.

  The user’s affect appears:
  
  1   flexible or adapted (apparent ability to feel 
      the full range of affective states)
  2   flat (appearance of detachment, absence, 
      neutrality, indifference)
  3   melancholic (tends to be sad, pessimistic, 
      depressed, negative)
  4   labile (tends to be unstable, unpredictable, 
      fickle)
  5   euphoric (tends to exaggerate or be exuberant 
      or overexcited)

4. BEHAVIOURAL STATE

  Refers to a significant propensity to act or 
react, bearing in mind personality, according to a
certain behavioural model.

  The user’s behaviour tends to be:
	
  1   appropriate to the circumstances (normality)
  2   marginal, bizarre (marginality)
  3   excessively passive (disproportionate tendency 
      to remain inactive)
  4   disturbing, provocative or hyperactive 
      (disproportionate tendency to be active)
  5   compulsive, unpredictable or uncontrolled
      (deviance)
	
5. RELATIONAL AND SOCIAL STATE	
  
  Refers to interaction within the primary and 
secondary networks outlined below and excludes 
interaction in the care facility.  The relational 
and social state situates the user in relation to 
the array of social networks with which he 
interacts, regardless of the nature of the 
interaction.

  Social networks:
  
  - Family ties (nuclear family, extended 
family)
  
  - No family ties (friends, neighbours, 
peers)
  
 - Formal or institutional (interveners in
the service network)

  - Informal or community (self-help groups, 
recreational groups and so on)

  N.B.: When the user’s interaction is confined to
people in the care facility, including other 
beneficiaries, circle the fifth descriptor.

  The user interacts with:
  
  1   all networks (4/4)
  2   most networks (3/4)
  3   half of the network (2/4)
  4   few networks (1/4)
  5   none of the networks (0/4)
  
SECTION B: MEASUREMENT OF PHYSICAL
FUNCTIONING

  "Functioning" represents the more dynamic or
fluctuating nature of the trait, actualization, 
operationalization, the degree of realization or 
expression.  In the case of all of these traits, 
the type of functioning is established on the basis
of direct or indirect observation by an outside 
observer of the attitudes or behaviour displayed
by the user, or of the user’s activities.

6. PHYSICAL FUNCTIONING
  
  Refers to the following everyday activities: 
hygiene, eating, dressing, bowel movements and 
mobility.  What is important is the result obtained,
regardless of the technical means used, e.g. 
ortheses, prostheses, wheelchairs, grab bars, canes,
adapted utensils, velcro fasteners, incontinence 
pads and so on.

  N.B.: In the case of a user whose ability to 
carry out everyday activities varies over time 
because, for example, of a cyclical physical 
illness such as arthritis, circle the third
descriptor.

  The user is functional with respect to:
  
  1   all everyday activities (5/5)
  2   most everyday activities (4/5)
  3   half of everyday activities (3/5 or 2/5)
  4   few everyday activities (1/5)
  5   no everyday activities (0/5)
	
7. COGNITIVE FUNCTIONING
  
  Refers to the following cognitive functions or
components: attention, understanding and judgment, 
memory, and orientation in time and space.  What is
important is the result obtained, regardless of the 
technical means used, e.g. topographical reference
points, reminders, learning and conditioning, 
role-playing, standard forms and so on.

  N.B.: In the case of a user whose functioning as 
regards the number of cognitive components varies 
sporadically over time because, for example, of 
significant fluctuations in tolerance to stress,
circle the third descriptor.

  The user is functional with respect to:
  
  1   all components (5/5)	
  2   most components (4/5)
  3   half of the components (3/5)
  4   few components (1/5)
  5   none of the components (0/5)
	
8. AFFECTIVE FUNCTIONING
  
  Does not refer to the nature of the emotion (fear,
tenderness, joy, anger), but to the degree of 
control exercised in expressing the emotion.

  The manner in which the user expresses emotions 
is usually:

  1   balanced (optimum control, appropriate 
      expression)
  2   stereotyped (learned control, automatism in 
      expression)
  3   inhibited (exaggerated control, repressed 
      expression)
  4   unstable (irregular control, unpredictable 
      expression)
  5   impulsive (absence or significant lack of 
      control, immoderate or unconsidered expression)

9. BEHAVIOURAL FUNCTIONING

  Refers to the way an individual acts in terms of
self-respect and respect for others.

  The user’s behaviour tends to be:
  
  1   assertive (positive, socially adapted 
      affirmation of self and, consequently, self-respect
      and respect for others)
  2   conciliatory, conformist, overly tolerant
  3   stubborn, rigid, obstinate or unstable
  4   manipulative
  5   aggressive, violent (no self-respect, failure 
      to respect others)

10. RELATIONAL AND SOCIAL FUNCTIONING

  Refers to the manner in which the user engages in
interaction, regardless of the individuals or 
networks involved.

  The user:
  
  1   displays an ability to approach or withdraw 
      depending on the circumstances (flexible, adapted)
  2   is afraid of social relations (timid, reserved,
      not overly inclined to withdraw)
  3   displays instability or temerity in social
      relations (unpredictable, careless)
  4   displays disproportionate social withdrawal 
      (isolated, introspective)
  5   displays a disproportionate social attraction 
      (overwhelming, stifling, social addict)                        

M.O. 93-04, Sch. I.