CHRIS CHRISTIE

GOVERNOR

KIM GUADAGNO

LT. GOVERNOR	STATE OF NEW JERSEY

DEPARTMENT OF HUMAN SERVICES

DIVISION OF DEVELOPMENTAL DISABILITIES

PO BOX 726

TRENTON, NJ 08625-0726

Jennifer Velez

COMMISSIONER

Dawn Apgar

Deputy Commissioner

TEL. (609) 631-2200

Adaptive Behavior Summary/Health Safety Risk Summary (ABS/HSRS) Acknowledgement Form

This is to acknowledge that I am the person who has completed the ABS/HSRS Form for ______________________________.

To the best of my knowledge and belief, the answers I have provided accurately reflect __________________________’s Self-Help Skills, Communication Skills, Social Behaviors, Community Awareness, Physical Conditions, Limitations, Assistive Devices as well as Health, Medical and Safety concerns.

Signature: ____________________________________________ Date:___________

Name (Please Print):____________________________________________________

Relationship:___________________________________________________________

New Jersey Is An Equal Opportunity Employer

To: Focus Group Participant

Monica Johnson

2011-11-14

NJ Dept. of Human Services

Human Services