Private: Older Blind Services Policy Manual

OBS – Appendix D

Revised 09/2007

INSTRUCTIONS FOR FORMS OBS-1/OBS-2
OLDER BLIND GRANT DATA SHEET

The following instructions are provided as a guideline for completing the OBS forms. Be sure to reference them whenever necessary and when you have a question regarding the data needed. Note, when (OTHER) is used, please specify what disability being placed under (OTHER).

REFERRAL DATE – Enter the date on which the client was referred. A referral may be received by telephone, in the mail, made in person, or when visiting another client.

CASELOAD NUMBER – Enter the caseload number of the Rehabilitation Teacher managing the case.

PREVIOUS OBS CASE Enter yes or no if the client has been previously served under the OBS Program, if not, check no.

IF YES-DATE OF CLOSURE– If yes, enter the date/dates the previous case was closed.

NAME– Enter the client’s name, last name first, followed with the first name, then the middle initial.

ADDRESS – (STREET OR RR) – Enter the street name and address or rural route on which the client is residing.

CITY/STATE/ZIP – Enter the name of the city, state, and zip code in which the client resides.

COUNTY AND NUMBER– Enter the name and number of the county in which the client resides.

PHONE -Enter the telephone number at which the client may be reached. Here, home, and when available work, numbers must be used. If the client does not have a personal number where he or she can be reached, then a contact number must be provided.

CASE NUMBER – Enter the OBS case number as assigned by the district office.

SOCIAL SECURITY NUMBER – Enter the client’s social security number.

DATE OF BIRTH – Enter the client’s date of birth, beginning with the month, followed by the day, and then the year. Use two digits for each field.

DATE OF ELIGIBILITY – Enter the date the client was determined eligible. The date entered in this field must be the same as the date on the Certification of Eligibility.

GENDER – Check the appropriate corresponding number.

(1) Female
(2) Male

RACE/ETHNICITY – Check the appropriate corresponding number used in the list below. The information recorded must reflect the individual’s own identification of race and ethnicity. Multiple responses are permitted for an individual.

(1) White (Non-Hispanic) – A person having origins in any of the original peoples of Europe, North Africa, or the Middle East.

(2) African-American (Non-Hispanic) – A person having origins in any of the black racial groups of Africa.

(3) American Indian or Alaskan Native – A person having origins in any of the original peoples of North America, and who maintains cultural identification through affiliation or community recognition.

(4) Asian – A person having origins in any of the original peoples of the Far East, Southeast Asia, the Indian subcontinent.

(5) Native Hawaiian or Pacific Islander – A person having origins in any of the original peoples of Hawaii or other Pacific Islands.

(6) Hispanic or Latino – A person having origins in any of the original peoples of Mexico, Puerto Rico, Cuba, El Salvador, the Dominican Republic, Guatemala, Honduras, Columbia, Panama and other Latin American countries.

(7) Other: (Specify)

VISUAL DISABILITY

(1) Totally Blind (LP only or NLP)

Check this box if the client is totally blind. That is, the client has either light perception or no light perception.

(2) Legally Blind (Excluding Total Blindness)

Check this box if the client has a visual acuity of 20/200 or worse, but more than light perception.

Reported/Snellen Acuity:

Enter the visual acuity in the space provided next to this box.

(3) Progressive Condition – 20/70 or worse corrected bilateral acuity

Check this box if the client has a visual acuity of 20/70 or worse, but more than 20/200.

Reported/Snellen Acuity:

Enter the visual acuity in the space provided next to this box.

MAJOR CAUSE OF VISUAL IMPAIRMENT (as reported by the individual) – Place a check mark next to all conditions that apply.

(1) Macular Degeneration

(2) Diabetic Retinopathy

(3) Glaucoma

(4) Cataracts

(5) Other

NON-VISUAL IMPAIRMENTS/CONDITIONS AT TIME OF INTAKE (as reported by the individual) – Place a check mark next to all conditions that apply.

(1) Hearing Impairment

(2) Mental Impairments (includes cognitive impairments involving learning, thinking, processing information and concentration; psychosocial impairments ( interpersonal and behavioral impairments, difficulty coping, Alzheimers and other mental impairments)

(3) Cancer

(4) Cardiac and other conditions of the Circulatory System

(5) Diabetes Mellitus

(6) End Stage Renal Disease and Genitou-Urinary System

(7) Musculoskeletal (Arthritis, Rheumatism, Amputations, Fractures/Injuries which resulted in permanent loss/impairment of limb function)

(8) Neurological Impairments/Disorders due to: Stroke (CVA) with resulting paralysis or weakness, peripheral or Diabetic neuropathy, other conditions affecting the central nervous system (includes Parkinson’s Disease, Seizure Disorders, Cerebral Palsy, Multiple Sclerosis, etc.)  

(9) Respiratory or lung conditions  

(10) Other (Specify)

ONSET OF SIGNIFICANT VISION LOSS – Place a check mark for the number of years when loss of vision began to affect the client’s performance of daily activities.

(1) Less than one year before IL services

(2) 1-3 years

(3) 4-6 years

(4) 7-9 years

(5) 10 years or more

HIGHEST LEVEL OF EDUCATION COMPLETED – Place check mark for the level of education the individual has attained at the time of application. If the client is uncertain about the highest grade completed, estimate the educational level.

(1) No formal schooling

(2) Elementary education (grades 1-8)

(3) Secondary education, no high school diploma (grades 9-12)

(4) High school or equivalency certificate

(5) Post secondary education (less than Bachelor’s degree)

(6) Bachelor’s degree or higher

(7) Master’s degree or higher

TYPE OF LIVING ARRANGEMENT AT TIME OF INTAKE – Indicate the living arrangements of the individual, either temporarily or permanently, on the date of application to the OBS Program using the list below.

(1) Live alone

(2) Live with spouse

(3) Live with personal care assistant

(4) Live with other

SETTING OF RESIDENCE AT TIME OF INTAKE – Indicate the type of residence of the individual at the time of application using the list below.

(1) Private residence apartment or home alone, or with roommate, personal care assistant, family or other person(s)

(2) Community residential – housing that provides residential services which include room, meals, daily living services, but not habilitative or health care.

(3) Assisted living center – housing that provides personal care and services which meet needs beyond basic provision of food, shelter, and laundry.

(4) Nursing home of Long Term Care Facility – any facility that provides care to one or more persons who require nursing care and related medical services of such complexity to require professional nursing care under the direction of a physician on a 24 hour a day basis.

(5) Other – any other living arrangement not listed above.

SOURCE OF REFERRAL – Indicate the individual agency, or other entity that first referred the individual to the OBS Program by using the list below.

(1) Eye care provider (ophthalmologist, optometrist)

(2) General practitioner, primary care provider, or other medical personnel or medical institution

(3) State VR agency counselor or other agency staff

(4) Social service agency

(5) Self-referral

(6) Family member or friend

(7) Veterans Administration

(8) Senior program

(9) Religious organization

(10) Community Rehabilitation Program

(11) Other sources (e.g. public service announcement)

The following statement must be read and explained to the client to ensure their full understanding of its implication on their rehabilitation process. Indicate the client’s response by checking the appropriate box. Applicant must sign and date this form.

DO YOU FEEL, AFTER DISCUSSION OF THE SERVICES OFFERED BY REHABILITATION SERVICES FOR THE BLIND, THAT YOUR HEALTH WILL ALLOW YOU TO BE MORE INDEPENDENT?

FORM OBS-2 INSTRUCTIONS

NAME – Enter the client’s name, last name first, followed with the first name, then the middle initial.

CASE NUMBER – Enter the OBS case number as assigned by the district office.

SOCIAL SECURITY NUMBER – Enter the client’s social security number.

CASELOAD NUMBER – Enter the caseload number of the Rehabilitation Teacher managing the case.

FEDERAL FISCAL YEAR – (Federal Fiscal Year runs from October 1 through September 30). Enter the Federal Fiscal Year in which the case is being closed. (10-01-XX through 9-30-XX).

SERVICES/ TRAINING PROVIDED – TOTAL NUMBER OF HOURS– Include all services furnished whether paid for with OBS funds or from other comparable services. Record the number of hours spent on providing each individual service. The following are types of training that may be provided to OBS clients (Training hours only are recorded):

Orientation and Mobility – Individual hours – Learning to move around safely in one’s home or community.

Communication Skills – Individual hours – includes training in skills such as, telling time, reading and writing Braille, dialing a telephone, identifying money, using writing guides, keyboarding, etc.

Daily Living Skills – Individual hours – includes skills such as, personal management to include personal grooming, identifying and matching colors, care of clothing, etc., learning meal preparation; home management to include cleaning and keeping the home in order.

Low Vision Training – Individual hours – This service includes training in how to use remaining vision effectively, such as the use of low vision aids, learning eccentric viewing, learning how to use residual side vision to read and perform tasks typically done with central vision. A low vision aid is any aid that has a magnification of 3.50 or above. This does not include low vision exams.

Advocacy – Individual hours – Advocacy training includes training the client in self-advocacy skills. Self-advocacy means to speak up or advocate for one’s self; to speak up for personal rights or against personal discrimination; making one’s needs known in an assertive and positive m anner; and getting one’s needs met in an appropriate way.

Management of Secondary Disabilities Individual hours – Examples of this service would include: instruction on management of diabetes including coping with dietary restrictions, taking insulin; weight management, dealing with arthritis problems, etc.

OTHER INDIVIDUAL SERVICES – TOTAL NUMBER OF HOURS

Counseling (individual, peer support, mentoring, family) – Individual hours – *Note, please check this field on every completed OBS-2 form. Counseling may include individual counseling with personnel on staff; counseling provided by a trained peer on a one-to-one basis and family counseling with personnel on staff.

Readers/Guides/Interpreters – Individual hours – Provision of volunteers or staff to read mail, etc. and use of sighted guides to get to medical, recreational activities, etc. Purchase of interpreter services for the provision of IL services to individuals who are deaf.

Referral for VR services – Individual hours – Referral to VR counselor, to one-stop center or Title V (of the Older Americans Act).

Referral to other agencies – Individual hours – Connecting the client with other agencies/organizations within the vision field and outside the field such as agencies serving the elderly, the health system, and home health care.

Support groups – Individual hours – Support groups conducted by a staff member as facilitator, or by another older visually impaired peer as the facilitator).

Community integration – Individual hours – Assisting client with activities to get reinvolved in the life of the community again for social interaction, educational, or recreational purposes. Can include attending a senior center or other senior citizens group, going back to church.

Other Services – Enter any type of service provided that does not fall under any other category listed above.

TOTAL DOLLARS SPENT

Low Vision Screening – This includes cost of low vision exams.

Low Vision Aids – Enter total cost of low vision aids provided to client.

Other Adaptive Aids/Equipment – Enter total cost of communication aids such as watches, telephone, Braille equipment, writing guides, etc., home appliances, and equipment purchased for management of secondary disabilities.

Transportation – Enter total cost of transportation services provided.

Visual Restoration – Enter the total cost of surgery and treatment for eye conditions and regular prescription eye glasses.

CLOSURE:

CLOSED STATUS 26 – Indicate this status when the client has successfully completed the rehabilitation process. Enter closure date.

CLOSED STATUS 28 – Indicate this status when a case is being closed before the rehabilitation process has been completed. Enter closure date.

ELIGIBLE BUT NOT CLOSED – Indicate this category only when submitting the year end OBS-2 (9-30) services provided for cases being carried over to the next fiscal year.