Form for Assessment of Attendant Care Needs – Accidents After December 31, 1993 and Before November 1, 1996








Use this form to report the future needs for attendant care required by the client as a result of an automobile accident. This form has five parts:

Part 1: Level 1 Attendant Care
Part 2: Level 2 Attendant Care
Part 3: Level 3 Attendant Care
Part 4: Calculation of Attendant Care Costs
Part 5: Signature of Assessor(s)

Please complete all relevant parts. You will have to make copies and give one to:


Client’s Name





Date of Birth



Date of Accident

















What is the date of this assessment?

Is this the first assessment of this client?

Date of Last Assessment





Client’s Health Practitioner




Telephone Number









Insurance Company




Telephone Number















Part 1: Level 1 Attendant Care

Level 1 attendant care is for routine personal care. Please assess the care requirements of the client for each activity listed. Estimate the time it takes to perform each activity, and the number of times each week it should be performed. Multiply the number of minutes by the number of times each week the activity should be performed to get the total number of minutes per week for each activity.

Level 1 Attendant Care: Dress
Number of Minutes Times per week Total minutes per week
Upper Body (for example, underwear, shirt/blouse, sweater, tie, jacket, gloves, jewelry)
Lower Body (for example, underwear, disposable briefs, skirt/pants, socks, panty hose, slippers shoes)
    Subtotal


Level 1 Attendant Care: Undress
Number of Minutes Times per week Total minutes per week
Upper Body (for example, underwear, shirt/blouse, sweater, tie, jacket, gloves, jewelry)
Lower Body (for example, underwear, disposable briefs, skirt/pants, socks, panty hose, slippers shoes)
    Subtotal


Level 1 Attendant Care: Prosthetics
Number of Minutes Times per week
Total minutes per week
applies to upper/lower limb prosthesis and stump sock(s)
exchanges terminal devices and adjusts prosthesis as required
ensures prosthesis is properly maintained and in good working condition
    Subtotal


Level 1 Attendant Care: Orthotics
Number of Minutes Times per week Total minutes per week
assists dressing client using prescribed orthotics (for example, burn garment(s), brace(s), supports, splints, elastic stockings)
    Subtotal


Level 1 Attendant Care: Grooming
Number of Minutes Times per week Total minutes per week
Face: wash, rinse, dry, morning and evening
Hands: wash, rinse, dry, morning and evening, before and after meals, and after elimination
Shaving: shaves client using electric/safety razor
Cosmetics: applies makeup as desired or required
Hair
brushes/combs as required
shampoos, blow/towel dries
performs styling, set and comb-out
Fingernails: cleans and manicures as required
Toenails: cleans and trims as required
    Subtotal


Level 1 Attendant Care: Feeding
Number of Minutes Times per week
Total minutes per week
prepares client for meals (includes transfer to appropriate location)

provides assistance, either in whole or in part, in preparing serving and feeding meals
    Subtotal


Level 1 Attendant Care: Mobility
(location change such as to and from the bedroom for afternoon rests)
Number of Minutes Times per week Total minutes per week
assists client from sitting position (for example, wheelchair, chair, sofa)
Supervises/assists in walking
performs transfer needs as required (for example, bed to wheelchair, wheelchair to bed)
    Subtotal


Level 1 Attendant Care: Extra Laundering
Number of Minutes Times per week Total minutes per week
launders client’s bedding and clothing as a result of incontinence spillage

launders/cleans orthotic supplies that require special care
    Subtotal






Part 2: Level 2 Attendant Care

Level 2 attendant care is for basic supervisory functions. Please assess the care requirements of the client for each activity listed. Estimate the time it takes to perform each activity, and the number of times each week it should be performed. Multiply the number of minutes by the number of times each week the activity should be performed to get the total number of minutes per week for each activity.

Level 2 Attendant Care: Hygiene
Number of Minutes Times per week Total minutes per week
Bathroom
cleans tub/shower/sink/toilet after client’s use
Bedroom
changes client’s bedding, makes bed, cleans bedroom, including Hoyer lifts, overhead bars, bedside tables
ensures comfort, safety and security in this environment
Clothing Care
assists in preparing daily wearing apparel
hangs clothes and sorts clothing to be laundered/cleaned
    Subtotal


Level 2 Attendant Care: Ventilator Dependant
(high level quadriplegic or approximate)
Number of Minutes Times per week Total minutes per week
client lacks the capacity to reattach tubing if it becomes detached from the trachea
client lacks the physical capacity to be self-sufficient in an emergency situation
    Subtotal


Level 2 Attendant Care: Spinal Cord Injuries
(paraplegic / quadriplegic)
Number of Minutes Times per week Total minutes per week
client requires assistance to transfer from bed to wheelchair, periodic turning, genitourinary care
client lacks the physical capacity to be self-sufficient in an emergency situation
    Subtotal


Level 2 Attendant Care: Severe Head Injuries
Number of Minutes Times per week Total minutes per week
client lacks ability to respond to an emergency or needs custodial care due to changes in behaviour
    Subtotal


Level 2 Attendant Care: Attendant Care on an Intermittent Basis
Number of Minutes Times per week Total minutes per week
client lives alone or is left alone in the day, determine the degree to which the client may be dependent on other (for example meals, laundry, housekeeping)
client may be independent during the day when in a wheelchair or wearing a prosthesis, but needs assistance for meals, laundry
    Subtotal


Level 2 Attendant Care: Multiple Amputations
(upper bilateral, triple, quadruple amputee)
Number of Minutes Times per week Total minutes per week
client lacks the ability to independently get in and out of a wheelchair or to be self-sufficient in an emergency
    Subtotal


Level 2 Attendant Care: Financial Affairs
Number of Minutes Times per week Total minutes per week
client requires assistance in managing financial affairs (maximum 1 hour per week)
    Subtotal






Part 3: Level 3 Attendant Care

Level 3 attendant care is for complex health / care and hygiene functions. Please assess the care requirements of the client for each activity listed. Estimate the time it takes to perform each activity, and the number of times each week it should be performed. Multiply the number of minutes by the number of times each week the activity should be performed to get the total number of minutes per week for each activity.

Level 3 Attendant Care: Genitourinary Tracts
Number of Minutes Times per week Total minutes per week
performs catheterizations
positions, empties and cleans drainage systems
cleans client and equipment after procedure / incontinence
uses disposable briefs as required
attends to menstrual cycle needs as required
monitors residuals
    Subtotal


Level 3 Attendant Care: Bowel Care
Number of Minutes Times per week Total minutes per week
administers enemas or suppositories and performs stimulation or disimpaction
performs colostomy and / or ileostomy care
positions, empties and cleans drainage systems, including ilio-conduits
uses disposable briefs as required
cleans client and equipment after procedure / evacuation
    Subtotal


Level 3 Attendant Care: Tracheostomy Care
Number of Minutes Times per week Total minutes per week
changes and cleans inner and outer cannulae as needed
changes tapes as required
performs suctioning as required
cleans and maintains suction equipment
    Subtotal


Level 3 Attendant Care: Ventilator Care
Number of Minutes Times per week Total minutes per week
ensures volume rate and pressure are maintained as prescribed
maintains humidification as specified
changes and cleans tubing and filters as required
cleans humidification system as required
adjusts settings according to client needs (for example, colds, congestion)
    Subtotal


Level 3 Attendant Care: Excersise
Number of Minutes Times per week Total minutes per week
assists client with prescribed exercise / stretching program
assists client with walking activities using cruches, canes, braces and / or walker
    Subtotal


Level 3 Attendant Care: Skin Care (excluding bathing)
Number of Minutes Times per week Total minutes per week
attends to skin care needs – wounds, sores, eruptions, (amputees, severe burns, spinal cord injuries, etc.)
applies medication and prescribed dressings
applies creams, lotions, pastes, ointments, powders as prescribed or required
checks body area(s) for evidence of pressure sores, skin breakdown or eruptions
periodic turning to prevent or minimize pressure sores and skin breakdown / shearing
    Subtotal


Level 3 Attendant Care: Medication
Number of Minutes Times per week Total minutes per week
Oral
administers prescribed medications
monitors medication intake and effect
maintains and controls medication supply
Injections
administers prescribed medications
monitors medication intake and effect
maintains and controls medication supply
Inhalation / Oxygen Therapy
administers prescribed dosage as required
maintains and controls inhalation supplies
cleans and maintains equipment
    Subtotal


Level 3 Attendant Care: Bathing
Number of Minutes Times per week Total minutes per week
Bathtub or Shower
transfers client to and from bed, wheelchair or Hoyer lifts to bathtub or shower
bathes and dries client
applies creams, lotions, pastes, ointments, powders as prescribed or required
Bed Bath
prepares equipment
bathes and dries client
applies creams, lotions, pastes, ointments, powders as prescribed or required
cleans and maintains bed / bath equipment
Oral Hygiene
brushes and flosses
cleans mouth as required
cleans dentures as required
    Subtotal


Level 3 Attendant Care: Other Therapy
Number of Minutes Times per week Total minutes per week
Transcutaneous Electrical Nerve Stimulation (TENS)
prepares equipment
administers treatment as prescribed or required
Dorsal Column Stimulation (DCS)
monitors skin
maintains equipment
    Subtotal


Level 3 Attendant Care: Maintenance of Supplies and Equipment
Number of Minutes Times per week Total minutes per week
monitors, orders and maintains required supplies / equipment
ensures wheelchairs, prosthetic devices, Hoyer lifts, shower commodes and other specialized medical equipment and assistive devices are safe and secure
    Subtotal



Part 4: Calculation of Attendant Care Costs

This part must be completed by the assessor. Calculate the monthly attendant care allowance for Part 1, 2 and 3. The sum of all three parts will be the Total Assessed Monthly Attendant Care Benefit.

Total Minutes
per Week (A)
  Total Weekly
Hours (B)
  Total Monthly
Hours (C)
  Hourly Rate (D)   Monthly Care
Benefit
(E)
Part 1 /60 = x 4.3 = x $ = $
Part 2 /60 = x 4.3 = x $ = $
Part 3 /60 = x 4.3 = x $ = $
 

Total Assessed Monthly Attendant Care Benefit

(This amount is subject to the limits allowed under the Statutory Accident Benefits Schedule)
$

Part 5: Signature(s) of Assessor(s)






Date





Telephone Number


Fax Number