Form 28-0791 Pre and Post Independent Living Assessment

OMB Approved No. 2900-0681
Respondent Burden: 30 Minutes
Expiration Date: XX/XX/20XX

PRE AND POST
INDEPENDENT LIVING ASSESSMENT
INSTRUCTIONS: Before the Vocational Rehabilitation Counselor (VRC) completes this form, read the Privacy Act and
Respondent Burden on page 5. This form is used for evaluation of the claimant's independent living (IL) needs. For more
information, contact us at https://ask.va.gov or call us toll-free at 1-800-827-1000. If you use a Telecommunications
Device for the Deaf (TDD), the Federal relay number is 711. VA forms are available at www.va.gov/vaforms.
Activities of Daily Living (ADLs) are basic tasks a person needs to be able to do on his or her own to live independently.
ADLs include bathing, showering, toileting, dressing, walking, eating meals, personal hygiene, mobility, cleaning and
housekeeping, laundry, managing money or medications, shopping, meal preparation, transportation, using
communication devices and more.
NOTE: This evaluation contains two assessments on this form that must be completed before and after the provision of
independent living services to a claimant. The VRC must read the questions below to the claimant and complete the form
with the claimant's responses. Post IL assessment questions will only be completed for section I. The VRC must compare
the information obtained from the preliminary and post plan assessments to determine if there are improvements in the
claimant's activities of daily living.
• Preliminary Assessment: A preliminary evaluation of IL needs must be conducted with the claimant to determine
if there is a need to conduct a comprehensive IL assessment and consequently develop a plan of IL services for a
claimant as outlined in M28C.IV.C.6. Respond to all questions outlined below.
Post Plan Assessment: In accordance with M28C.IV.C.6, the VRC must use this form when assessing post plan
improvements following the provision of services under an IILP. At the conclusion of a claimant's IL program,
there must be measurable improvements in the level of independence in daily living. Respond to questions #1
through #28 below only.

•

READ TO CLAIMANT: Activities of Daily Living: Your responses to the questions will assist in determining how much
difficulty you may have had in performing these activities during the past month. Difficulty is defined as how hard it was or
how much effort it took to complete an activity because of your disability(ies).
CLAIMANT'S INFORMATION
CLAIMANT'S NAME (First, Middle Initial, Last):

VA FILE NUMBER (last 4):

Using the assigned ratings below, select the number that most closely indicates your
response:
1 - Did not do for other reasons
2 - Did not do because of disability conditions
3 - Did with help or assistive device
4 - Did with some difficulty
5 - Did with no difficulty

DURING THE PAST MONTH, HOW MUCH DIFFICULTY DID YOU HAVE DOING THE FOLLOWING TASKS?

PART I - ACTIVITIES OF DAILY LIVING (ADLs)
1.

BATHING AND SHOWERING, MAINTAINING PERSONAL HYGIENE, BRUSHING TEETH, COMBING HAIR, AND NAIL CARE.
Preliminary Assessment:

1

2

3

4

5

Post-plan Assessment:

1

2

3

4

5

VA FORM
XXX XXXX

28-0791

SUPERSEDES VA FORM 28-0791, JUL 2021,
WHICH WILL NOT BE USED.

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PART I - ACTIVITIES OF DAILY LIVING (ADLs) (Continued)
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12.

DISTINGUISHING WATER AT A SAFE TEMPERATURE TO BATH AND SHOWER.
Preliminary Assessment:

1

2

3

4

5

Post-plan Assessment:

1

2

3

4

5

DRESSING, SELECT APPROPRIATE CLOTHES AND OUTWEAR FOR THE WEATHER OR OCCASION, AND GET DRESSED
INDEPENDENTLY.
Preliminary Assessment:

1

2

3

4

5

Post-plan Assessment:

1

2

3

4

5

MOBILITY, ABLE TO WALK OR TRANFER FROM ONE PLACE TO ANOTHER, SPECIFICALLY GETTING IN AND OUT OF A
SHOWER OR TUB, ON AND OFF A BED OR CHAIR.
Preliminary Assessment:

1

2

3

4

5

Post-plan Assessment:

1

2

3

4

5

TOILETING, ABLE TO GET ON AND OFF THE TOILET AND CLEAN YOURSELF WITHOUT ASSISTANCE, CONTINENCE ISSUES.
Preliminary Assessment:

1

2

3

4

5

Post-plan Assessment:

1

2

3

4

5

FEEDING (EXCLUDING MEAL PREPARATION), ABILITY TO GET FOOD FROM PLATE TO MOUTH, AND TO CHEW AND SWALLOW.
Preliminary Assessment:

1

2

3

4

5

Post-plan Assessment:

1

2

3

4

5

CLEANING AND HOUSEKEEPING, INCLUDING MAINTENANCE AND OTHER HOME-CARE CHORES.
Preliminary Assessment:

1

2

3

4

5

Post-plan Assessment:

1

2

3

4

5

DOING LAUNDRY, ABLE TO WASH AND DRY CLOTHES.
Preliminary Assessment:

1

2

3

4

5

Post-plan Assessment:

1

2

3

4

5

MANAGING MONEY AND FINANCES, INCLUDING BUDGETING, WRITING CHECKS, PAYING BILLS, AND AVOIDING SCAMS.
Preliminary Assessment:

1

2

3

4

5

Post-plan Assessment:

1

2

3

4

5

MANAGING MEDICATIONS, TAKING PRESCRIBED MEDICATIONS AS DIRECTED (CORRECT DOSE AT THE CORRECT TIME)
Preliminary Assessment:

1

2

3

4

5

Post-plan Assessment:

1

2

3

4

5

PREPARING MEALS AND SERVING MEALS (USING COOKWARE, UTENSILS, AND KNIVES).
Preliminary Assessment:

1

2

3

4

5

Post-plan Assessment:

1

2

3

4

5

SHOPPING, ABLE TO BUY GROCERIES, OTHER NECESSITIES, AND DO ERRANDS
Preliminary Assessment:

1

2

3

4

5

Post-plan Assessment:

1

2

3

4

5

VA FORM 28-0791, XXX XXXX

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PART I - ACTIVITIES OF DAILY LIVING (ADLs) (Continued)
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24.

TRANSPORTATION, ABLE TO DRIVE OR USE PUBLIC TRANSPORTATION, OR ARRANGE OTHER MEANS OF TRANSPORT.
Preliminary Assessment:

1

2

3

4

5

Post-plan Assessment:

1

2

3

4

5

COMMUNICATION DEVICES, USING THE PHONE OR COMPUTER.
Preliminary Assessment:

1

2

3

4

5

Post-plan Assessment:

1

2

3

4

5

GETTING IN AND OUT OF RESIDENCE.
Preliminary Assessment:

1

2

3

4

5

Post-plan Assessment:

1

2

3

4

5

WALKING INDOORS, SUCH AS AROUND YOUR HOME, ACCESSING ALL AREAS AND ROOMS OF YOUR LIVING SPACE.
Preliminary Assessment:

1

2

3

4

5

Post-plan Assessment:

1

2

3

4

5

Preliminary Assessment:

1

2

3

4

5

Post-plan Assessment:

1

2

3

4

5

WALKING SEVERAL BLOCKS.

CLIMBING UP AND DOWN A FLIGHT OF STAIRS.
Preliminary Assessment:

1

2

3

4

5

Post-plan Assessment:

1

2

3

4

5

REACHING OR BENDING TO ACCESS CABINETS THAT ARE OVERHEAD OR LOW, ELECTRICAL OUTLETS AT THE BACK OF
COUNTERS AND CLOTHES IN CLOSETS.
Preliminary Assessment:

1

2

3

4

5

Post-plan Assessment:

1

2

3

4

5

OPERATING FIXTURES TO INCLUDE DOORS, LOCKS, WINDOWS, SHADES, CURTAINS, OR FAUCETS.
Preliminary Assessment:

1

2

3

4

5

Post-plan Assessment:

1

2

3

4

5

OPERATING A FAN, THERMOSTAT, OR TV.
Preliminary Assessment:

1

2

3

4

5

Post-plan Assessment:

1

2

3

4

5

GRASPING WITH FINGERS AND FINE MOTOR SKILLS.
Preliminary Assessment:

1

2

3

4

5

Post-plan Assessment:

1

2

3

4

5

USING A KEYBOARD FOR TYPING ON A COMPUTER OR TEXTING ON A CELLPHONE.
Preliminary Assessment:

1

2

3

4

5

Post-plan Assessment:

1

2

3

4

5

SLEEPING (DO YOU REQUIRE GRAB BARS, WEDGE PILLOW, ETC.?)
Preliminary Assessment:

1

2

3

4

5

Post-plan Assessment:

1

2

3

4

5

VA FORM 28-0791, XXX XXXX

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PART I - ACTIVITIES OF DAILY LIVING (ADLs) (Continued)
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28.

MEMORY AND CONCENTRATION (ASSISTED TECHNOLOGY TO ASSIST).
Preliminary Assessment:

1

2

3

4

5

Post-plan Assessment:

1

2

3

4

5

PARTICIPATING IN SOCIALIZATION WITH RELATIVES, FRIENDS, COMMUNITY ACTIVITIES, SUCH AS RELIGIOUS SERVICES,
SOCIAL ACTIVITIES OR VOLUNTEER WORK.
Preliminary Assessment:

1

2

3

4

5

Post-plan Assessment:

1

2

3

4

5

TAKING CARE OF OTHER PEOPLE SUCH AS FAMILY MEMBERS (IS THERE ANYONE DEPENDENT ON YOU).
Preliminary Assessment:

1

2

3

4

5

Post-plan Assessment:

1

2

3

4

5

FOR ANY ACTIVITY WHICH YOU MARKED 3 OR LOWER, PROVIDE A DETAILED EXPLANATION:

VA FORM 28-0791, XXX XXXX

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PART II - HOUSING
Complete these sections only for the Preliminary Assessment.
29. WHERE DO YOU CURRENTLY LIVE?
Preliminary Assessment:

Apartment

Halfway House

Homeless Shelter

Private Home

Other

VA Domiciliary

Live Alone

Live with Friends

Live with Relatives

Live with Significant Other

Live with Spouse

Other (Please explain)

Own

Rent

30. WHO LIVES WITH YOU?
Preliminary Assessment:

31. ARE YOU HAVING ANY PROBLEMS IN YOUR CURRENT HOUSING OR LIVING ARRANGEMENTS?
Preliminary Assessment:

Yes

No (Please explain)

PART III - HOBBIES OR LEISURE ACTIVITIES
32. DO YOU HAVE ANY CURRENT HOBBIES OR AVOCATIONAL ACTIVITIES?
Preliminary Assessment:

33. IF YES, WHAT IS THE AMOUNT OF TIME YOU SPEND ON EACH ACTIVITY PER MONTH?
Preliminary Assessment:

34. HOW LONG HAVE YOU BEEN DOING EACH ACTIVITY?
Preliminary Assessment:

35. ARE THERE ANY OF THESE ACTIVITIES THAT YOU CAN NO LONGER DO BECAUSE OF YOUR DISABILITIES?
Preliminary Assessment:

PART IV - COMMENTS
36. ADDITIONAL COMMENTS

37. NAME OF VOCATIONAL REHABILITATION COUNSELOR

38. DATE (MM/DD/YYYY)

PRIVACY ACT NOTICE: VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of
1974 or Title 38, Code of Federal Regulations 1.576 for routine uses (i.e., civil or criminal law enforcement, congressional communications, epidemiological
or research studies, the collection of money owed to the United States, litigation in which the United States is a party or has an interest, the administration
of VA programs and delivery of VA benefits, verification of identity and status, and personnel administration) as identified in the VA system of records,
58VA21/22/28, Compensation, Pension, Education, and Veteran Readiness and Employment Records - VA, published in the Federal Register. Your
obligation to respond is voluntary
RESPONDENT BURDEN: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays
a currently valid OMB control number. The OMB control number for this project is 2900-0681, and it expires XX/XX/20XX. Public reporting burden for this
collection of information is estimated to average 30 minutes per respondent, per year, including the time for reviewing instructions, searching existing data
sources, gathering, and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden
estimate and any other aspect of this collection of information, including suggestions for reducing the burden, to VA Reports Clearance Officer at
VACOPaperworkReduAct@va.gov. Please refer to OMB Control No. 2900-0681 in any correspondence. Do not send your completed VA Form 28-0791 to
this email address.
VA FORM 28-0791, XXX XXXX

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