Self-Preservation Status

Participant Name: __________________________ Date: _______________________________

1. Ambulation: independent; independent with use of assistive device; not independent

2. Does the participant have the combined mental and physical capacity to:1

a) Recognize danger or an alarm requiring evacuation from the center? Yes No

b) Initiate and complete the evacuation without requiring more than

sporadic help in opening a door or getting into a wheelchair? Yes No

c) Select an alternative means of escape or take other appropriate action

if the primary route is blocked? Yes No

d) Remain at a designated location outside the center until further

instruction is given? Yes No

3. Based on the above, is the participant capable of self-preservation as defined

in the rules of the licensure? Yes No

Comments:
______________________________________________________________________________
______________________________________________________________________________

______________________________________________________________________________
(Signature of Participant or Legal Guardian - See Note Below) 2
(Relationship to Participant if applicable)

______________________________________________________________________________
(Signature of Program Representative)

1A participant is not capable unless they meet all of the above.

2Authorization is to be signed by the participant, the next of kin or legal guardian if participant is a minor or when participant is
physically or mentally unable to sign.

Katie Adult Day Center Policies and Procedures Manual 10-016.16