Fill and Sign the PDF Reporting on the Persistent Vegetative State in Europe Form

Does the person communicate independently with acquaintances in the community? If Recorded, What County(ies)? If Yes, Who has the POA? B. NUTRITION If Yes, Name of Trustee and location of trust County Of Residence 1. Can the person read and write? Are there any trusts in place? Does the person understand and participate in social conversation in his/her primary language (including such topics as sports, family, activities)? No Yes 5. GUARDIANSHIP CAPACITY QUESTIONNAIRE (Over) AOC-SP-208, New 6/042004 Administrative Office of the Courts This form can be used by the petitioner, the respondent, or any other person who has information that is useful to the court such as family or friends of the respondent or staff of a facility who knows the respondent well. It should be used by the Guardian Ad Litem to both gather the respondent' s answers if the respondent cannot fill it out for him/herself and for the GAL's own opinion. 6.If the person has a health condition such as diabetes, is he or she able to follow a prescribed diet? 1. 3. Can the person understand and respond to verbal communications? 2. Can the person understand various signs (e.g. keep out, stop, men, women, poison)? 4. Does the person make reasonable decisions regarding eating (e.g. when, where, and what to eat)? 2. Is the person able to eat and drink independently? 3 Is the person able to prepare food that requires cooking and mixing? Is the person able to prepare food that does not require cooking and mixing? Does the person know which foods, if any, he or she is unable to tolerate? Yes No With assistance Yes No With assistance Yes No With assistance Yes No With assistance Yes No With assistance Yes No With assistance Yes No Yes No Yes No Yes No 4. 5. Name Of Respondent Name And Address Of Person Completing This Form Address Is there a representative payee for governmental benefits? Yes No If Yes, Name of Payee Are there any Powers of Attorney in place? Yes No General/Durable Health Care Telephone No. Has Known Respondent (years/months) There is no need to complete this questionnaire if the respondent is in a coma, persistent vegetative state, or is not responsive. The questionnaire is designed to help all parties in an incompetency proceeding gather information that will a ssist the Clerk of Court in determining what if any rights, powe rs and privileges the respondent can retain under guardi anship or limited guardianship. The form may also assist the partie s in determining whether alternatives to guardianship such as a representative payee for government benefits, a power of attorney, or a special needs trust might solve a problem thereby avoiding the need for incompetency hearing. Nature Of Impairment Yes No Date Of Birth Telephone No. Relationship to the Respondent A. LANGUAGE AND COMMUNICATION 1. 1. 1. 1. 3.Does the person avoid common environmental dangers, such as oncoming traffic, sharp objects, a hot stove, and poisonous products? Can the person communicate medication problems or needs? AOC-SP-208, Side Two, New 6/04 7. Does the person understand the consequences of not accepting medical treatment? 8. Can the person reach emergency health care (e.g. calling an ambulance)?Yes No With assistance Yes No With assistance 1. Does the person bathe and maintain personal hygiene? Yes No With assistance C. PERSONAL HYGIENE 4. Is the person able to take care of minor health problems such as colds, cuts, etc.? 5. Is the person able to follow proper instructions in taking prescribed medicine? 6. Yes No With assistance Yes No With assistance Yes No With assistance E. PERSONAL SAFETY Can the person identify physical or sexual abuse and protect him or herself from personal harm by others? Can the person identify neglect and know what to do if neglected? 2. Yes No Yes No Yes No Can the person be left alone for periods up to 24 hours without being at risk? Can the person use a telephone to contact help in an emergency? E. PERSONAL SAFETY Cont. D. HEALTH CARE 1. Can the person make and communicate choices in regard to medical treatment? 3. Does the person know whom to notify of symptoms of illness?Yes No With assistance Yes No With assistance 2. Does the person brush teeth daily and maintain adequate dental care? Yes No With assistance 3. Does the person control toilet functions during the day? Yes No With assistance 4. When toileting, does the person use proper hygiene? Yes No With assistance 5. Is the person able to fully and properly dress and undress himself or herself? Yes No With assistance 6. Does the person wear clothing appropriate to the weather and/or occasion? Yes No With assistance 2. Can the person make and communicate choices in regard to caregivers and assistants? Yes No With assistance 4. 5. Yes No ' Yes No In what areas, if any, might the person be especially vulnerable and need protection? 6. Can the person make and communicate choices in regard to employment? Does the person express knowledge of or demonstrate skills required at job sites (neatness, punctuality, getting along with others)? Is the person able to use several approaches to finding a job (e.g. going to an employment agency, responding to ads, and using contacts)? Does the person have a job? Does the person interact appropriately with co-workers and authority figures? Yes No Yes No Yes No With assistance Yes No Yes No 2. 3. 4. 5. Can the person make and communicate choices in regard to residence and roommates? 2. Is the person able to maintain shelter that is safe/adequately heated and ventilated? 3. Can the person evacuate the premises in the case of fire or other danger? Yes No With assistance Yes No With assistance Yes No F. RESIDENTIAL Can the person initiate and follow a daily schedule of activities (e.g. when to get up, what to do, and when to go to bed)? Does the person acquire and retain new skills and readily apply them? Can the person avoid common dangers when traveling in the community? Can the person utilize familiar community resources (e.g. post office, stores, bus, bank)? Yes No Yes No Yes No Yes No Can the person identify his or her address and return home or seek assistance if lost or stranded? Yes No H. INDEPENDENT LIVING 2. 4. 3. 5. 2004 Administrative Office of the Courts G. EMPLOYMENT Does the person establish and maintain personal relationships with friends, relatives, co-workers? AOC-SP-208, Page Two, New 6/042004 Administrative Office of the Courts Name Of Respondent H. INDEPENDENT LIVING cont. ADDITIONAL COMMENTS 6.Yes No 7. Can the person determine his or her degree of participation in religious activities? 8. Does the person make and communicate choices in regard to leisure activities? 9. Can the person drive a car? 10. Does the person exercise reasonably good judgment most of the time?Yes No Yes No Yes No Yes No I. CIVIL 1. Does the person know whom to contact if he or she is being exploited or treated unfairly (e.g. police, DSS, Arc, lawyer, etc. 2. Does the person understand how to obtain legal counsel or advocacy services? 3. Is the person able to to communicate wishes regarding legal documents or services? 4. Does the person understand the consequences of being charged and convicted of a crime? 5. Does the person demonstrate a willingness to vote? Yes No Yes No Yes No Yes No Yes No Can the person make and communicate decisions to manage a budget? Does the person know the source and amounts of monetary benefits he or she receives on a weekly, monthly or annual basis? Does the person identify and make change for $1, $5, and $20? Can the person adequately maintain a bank account? Can the person protect and spend small amounts of money? Does the person understand the concept of a debt? Can the person identify and resist financial exploitation?Yes No With assistance Yes No With assistance Yes No Yes No With assistance Yes No With assistance Yes No With assistance Yes No J. FINANCIAL 1. 2. 3. 4. 5. 6. 7.