Community 3 Points 2 Points 1 Point 0 Points Score Comments Inclusion Goal(s) 0 at this level Score at this level when 2 Score at this level at this level when 0 when 3 of the of the components in this when 1 of the of the components in this The plan 1 components in this section are covered. components in this section are covered. identifies specific 2 section are covered. section are covered. community 3 Mark all included in the Community Inclusion Plan: contribution 4 1. The preferred community contribution or activities are listed preferences and a goal. 2. The Community Inclusion goal listed is specific and relates to the individual’s preferences Goals should and preferred activities relate to the 3. The Community Inclusion goal is specific and relates to the individual’s skills, gifts, community interests, and strengths contribution or connection 4. The activities in the plan meet the 4 elements of CI services (only check the box if all 4 preferences and elements are present): the individual’s Individualized skills, gifts, and interests. Local The reader Integrated should be able to clearly see the Has the ability to contribute to the community or develop meaningful relationships objective of the plan. Quality of 3 points 2 points 1 Point 0 Points Score Comments Services
Community Inclusion Goal(s) 3 Points 2 Points 1 Point 0 Points Score Comments The plan identifies specific community contribution preferences and a goal. Goals should relate to the community contribution or connection preferences and the individual’s skills, gifts, and interests. The reader should be able to clearly see the objective of the plan. at this level when 3 of the components in this section are covered. Score at this level when 2 of the components in this section are covered. Score at this level when 1 of the components in this section are covered. at this level when 0 of the components in this section are covered. 0 1 2 3 4 Mark all included in the Community Inclusion Plan: 1. The preferred community contribution or activities are listed 2. The Community Inclusion goal listed is specific and relates to the individual’s preferences and preferred activities 3. The Community Inclusion goal is specific and relates to the individual’s skills, gifts, interests, and strengths 4. The activities in the plan meet the 4 elements of CI services (only check the box if all 4 elements are present): Individualized Local Integrated Has the ability to contribute to the community or develop meaningful relationships Quality of Services 3 points 2 points 1 Point 0 Points Score Comments