DDD FINAL COVID-19 Benefit/Risk Discussion Tool

Illinois Department of Human Services/Division of Developmental Disabilities
COVID-19 Benefit/Risk Tool

Date:

Name:

CDS Provider Name:

This tool is meant to facilitate a discussion with an individual, guardian (if applicable), family, caregiver(s) housemate(s) and other service providers when considering the return to Community Day Services (CDS). It should be used to weigh the benefits and risks of return. This is solely for use as a planning tool and does not determine eligibility to return to CDS.

Please consult with the individual's primary health care providers for specific health care considerations related to the return to CDS, including any potential mitigation of risks.

Check and answer each question and/or statement that applies to the individual.

Reference Resources:

A. Considerations for the Individual

Please describe the reasons why the individual would like return to their CDS program (routine, socialization, medical support, lack of day supervision):

What other options has the individual considered or participated in:

HBS only: Has the individual explored using PSWs for support?
- Yes
- No
CILA only: Has the individual explored the At-Home Day Program option?
- Yes
- No
Other:

B. Individual Situational Risks

Check all that apply and indicate suggestions to mitigate Individual Situational Risks.

The individual is not able to follow the social distancing protocol (6 feet of distance)
The individual is able to follow social distancing protocol with regular or minimal prompting
The individual is not able to tolerate a mask
The individual is able to tolerate a mask for short periods of time
The individual is able to tolerate a mask with regular prompting
The individual requires physical prompting/assistance to complete ADLs, such as toileting, eating, or mobility
The individual can independently complete ADLs, such as toileting, eating or mobility AND has control of all bodily fluids.
The individual has habits or behaviors such as putting his/her hands in their mouth, eyes or face, reaching for or touching other people or objects which put him/her at higher risk of infection

Suggestions for mitigating Individual Situation Risks:

C. Individual Risks (specific to the individual and their return to CDS)

Check and list all risks specific to the individual and suggestions to mitigate these risks.

Individual Risk:
Individual Risk:
Individual Risk:
Individual Risk:
Individual Risk:
Individual Risk: Not applicable

Suggestions for mitigating Individual Risks:

D. Individual Health Related Risks

Based on CDC guidance "People who are at risk of more severe illness" https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-at-higher-risk.html Using the CDC website (for most up to date information) check all that apply and indicate which health conditions the individual place the individual at increased risk:

The individual is over the age of 60
The individual is over the age of 70
The individual is over the age of 80
Health Condition:
Health Condition:
Health Condition:
Health Condition:
Health Condition:

Suggestions for mitigating Individual Health Related Risks:

E. Home & Related Parties Risks (Risks to others who live with the individual, e.g. family, roommates, caregivers)

Check all that apply and indicate suggestions to mitigate Home & Related Parties Risks

The individual is over the age of 60
The individual is over the age of 70
The individual is over the age of 80
Someone in the home has a health condition that puts them at risk of more severe illness per the CDC: https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-at-higher-risk.html
Other Risk:
Other Risk:
Other Risk:

Suggestions for mitigating Home & Related Parties Risk:

F. Other Considerations:

N/A

G. Recommendation:

Return to CDS
Delay return to CDS

If delayed, when should this be reviewed again:

H. Provide the names of those who participated in the discussion as applicable (this must include the individual and their guardian/family member):

Individual:

Guardian/Family Member:

Those living with Individual:

Other:

ISC:

CDS Provider:

Residential Provider (If Applicable):

Completed By: