Name:	                                       				  Date of birth:              				          
Date of assessment:                 					  Date of motor accident				
Hospital/unit:                                   								 		 
Method of administration:   Direct observation    Interview with:                                              			

Area	Score	Is score due to the burns?	Explain reasons for giving this score	
SELF CARE
	
1.Eating		 Yes 
 No
		
2.Grooming		 Yes 
 No
		
3.Bathing		 Yes 
 No
		
4.Dressing– Upper Body		 Yes 
 No
		
5.Dressing– Lower Body		 Yes 
 No
		
SPHINCTER CONTROL
	
6.Toileting		 Yes 
 No
		
7.Bladder management		 Yes 
 No
		
8.Bowel management		 Yes 
 No
		
Self care subtotal				
TRANSFERS
	
9.Transfers: Bed/ Chair/Wheelchair
		 Yes 
 No
	Mode:  W– Walk     C- Wheelchair    B- Both	
10.Transfers: 
Toilet		 Yes 
 No
		
11.Transfers: Bath/Shower		 Yes 
 No
		
LOCOMOTION
	
12.Walk/ Wheelchair		 Yes 
 No
	Mode:  W– Walk     C- Wheelchair    B- Both	
13.Stairs		 Yes 
 No
		
Mobility subtotal				

Area	Score	Is score due to the burns?	Explain reasons for giving this score	
COMMUNICATION
	
14.Comprehension

		 Yes 
 No
	Mode:  A – Auditory     V - Visual          C - Both

	
15.Expression

		 Yes 
 No
	Mode:  V – Vocal       N - Non-vocal      B - Both

	
SOCIAL COGNITION
	
16.Social interaction
		 Yes 
 No
		
17.Problem solving		 Yes 
 No

	
18.Memory		 Yes 
 No
		
Cognition subtotal				
FIM™ TOTAL SCORE				

Administered by:                                   	        		  FIM™ credentialed:   Yes    No     
Signature:						  Date of assessment:                 			        	

FIM™ LEVELS

No helper
7 Complete Independence (Timely, Safely)
6 Modified Independence (Device)

Helper – Modified Dependence
5 Supervision (Subject = 100%)
4 Minimal assistance (Subject = 75% or more)
3 Moderate assistance (Subject = 50% or more)

Helper – Complete Dependence
2 Maximal assistance (Subject = 25% or more)
1 Total assistance (Subject less than 25%)

Contact details for queries about eligibility for the Lifetime Care and Support Scheme:
Lifetime Care and Support Authority Commissioner of the ACT: www.act.gov.au/LTCSS
Phone: 132281  	   
Email: ltcss@act.gov.au