N.Y. Comp. Codes R. & Regs. tit. 14, Appendices, app 14

CERTIFICATION OF SELF-PRESERVATION TEST MATERIAL

This packet includes tests for capability of self-preservation. A person must pass either the Standard or Modified Certification Test in order to live in a community residence for the purpose of receiving residential core. The person's answers to the questions must be recorded on the test form with A PIECE OF CARBON PAPER INSERTED BETWEEN THE ORIGINAL AND SECOND COPIES. The forms must be filled out by a qualified professional.

Both the Standard and the Modified Tests may be administered in one of two ways:

1) Questions 1-2 may be administered at the referral site as a means of pre- screening the applicant. If both questions are answered satisfactorily, the second part of the test (Question #3) must then be administered at the proposed community residence site. The community residence shall complete the instrument and shall return the carbon copy of the completed instrument to the referring agency, facility or program.

2) Where there has been no referral, the entire test may be administered at the proposed community residence. If the applicant is certified as capable of self-preservation, the community residence shall send the carbon copy of the certification instrument to the department regional office within seven days after the person becomes a resident. Any such copy shall include the first name, last initial and date of birth of the person so certified but shall not include any other identifying information. If a person fails the Standard Test he/she may be given the Modified Test immediately or may be trained and re-tested with the Standard Test, provided that there be a 24 hour interval between the last training and the testing day. If the individual fails the Modified Test, he/she may be trained and re-tested, provided that there is a 24 hour interval between the last training and the testing day.

GENERAL AND LIMITED CERTIFICATION

Persons tested according to the Standard or Modified Test may be given General or Limited Certification.

General Certification means that a person is capable of self-preservation from all locations within the community residence.

Limited Certification means that a person is capable of self-preservation only from a certain location(s) within the community residence. For example, a person with a physical handicap light be capable of leaving the residence within two and half minutes from the ground floor only - in this case, she/he would receive limited certification with the limitations placed on his living situation specified on the instrument.

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N.Y. Comp. Codes R. & Regs. tit. 14, Appendices, app 14