Traumatic Brain Injury Program Manual
Regional Resource Development Specialist (RRDS)- Participant Interview
- B-1.1 Applicant Interview Acknowledgement (PDF, 13KB, 1pg)
- B-1.2 Application for Participation (PDF, 17KB, 1pg)
- B-1.3 Freedom of Choice (PDF, 12KB, 1pg)
- B-1.4 Service Coordinator Selection (PDF, 16KB, 1pg)
- B-1.5 Provider Selection Form (PDF, 16KB, 1pg)
Service Plan Forms - Initial Service Plan
- C-1.1 Application Packet (List of contents) (PDF, 14KB, 1pg)
- C-1.2 Initial Service Plan (PDF, 122KB, 22pg)
- C-1.3 Plan for Protective Oversight (PPO) (PDF, 35KB, 5pg)
- C-1.5 Waiver Services Contact List (PDF, 16KB, 2pg)
- C-1.6 Waiver Participant Rights and Responsibilities (PDF, 32KB, 3pg)
Emods, Assistive Technology, Community Transition Services
- C-2.1 Environmental Modification (E-Mod) Project Description and Cost Projection (PDF, 18KB, 1pg)
- C-2.2 Waiver Services Final Cost (PDF, 13KB, 1pg)
- C-2.4 Assistive Technology (AT) - Project Description and Cost Projection (PDF, 18KB, 1pg)
- C-2.5 Assistive Technology Final Cost (PDF, 10KB, 1pg)
- C-2.6 Community Transition Service (CTS) Project Description and Cost Projection (PDF, 28KB, 3pg)
- C-2.7 Community Transition Services Final Cost (PDF, 10KB, 1pg)
Revised Service Plans
- C-4.1 Revised Service Plan (PDF, 207KB, 16pg)
- C-4.2 Individual Service Report (PDF, 53KB, 1pg)
- C-4.3 Addendum to Existing Service Plan (PDF, 40KB, 5pg)
- C-4.4 Change of Provider Request (PDF, 17KB, 1pg)
- C-4.5 Change of Service Coordinator Request (PDF, 22KB, 1pg)
- C-4.6 Team Meeting Summary (PDF, 22KB, 1pg)
Serious Reportable Incident (SRI) forms
- D-1 SRI Provider Initial Report (PDF, 70KB, 1pg)
- D-2 SRI Provider 24 Hour Report (PDF, 31KB, 3pg)
- D-2(a) SRI Service Coordination 24 Hour Notification (PDF, 19KB, 1pg)
- D-3 SRI Provider Follow-up Report(s) (PDF, 16KB, 2pg)
Other Forms
- E-1 Home Assessment Abstract - DSS- 3139 (PDF, 133KB, 6pg)
- E-2 Home Assessment Abstract - Instructions (PDF, 59KB, 10pg)
Revised: September 2010
