Level of Care Worksheet

Use the worksheet below to determine a person's level of care. The calculated level of care will determine which Adult Care Home offers the appropriate level of services.

Instructions: Check the box which matches the amount of help required by the person needing care for each activity of daily living.

Note: "Activities of Daily Living" (ADL) are routine activities we perform for self-care such as eating, bathing, toileting, dressing and grooming.

Independent: Does not need someone's help to perform the ADL; may need assistive devices or set-up.

Assist: Even with devices, person needs help with parts of the ADL including cueing or stand-by.

Full Assist: Even with assistive devices the person is unable to perform any part of the ADL.

For more information about ADL see: Appendix I Activities of Daily Living (ADL)

Independent Assist Full Assist
Eating / Nutrition
Dressing / Grooming
Bathing / Personal Hygiene
Toileting (Elimination)
Mobility / Transfer
Behavior Management

Note: This worksheet is a guideline only. The results of a formal screening by a licensed Adult Care Home Operator may differ from the findings above, and will actually determine the level of care and class of home needed.