Risk Identification

Risk Identification Tool

The Risk Identification Tool is designed to assist teams in identifying any known, serious risks that are present in the person's life.

For purposes of this tool, serious risks are considered things that would likely result in hospitalization, institutionalization, serious financial hardship, legal action, or place the person or others in imminent harm unless specific, individualized support is in place.

Risk Identification Tool

Once any risk is identified, the SC/PA discusses it with the person and his/her ISP team to identify the best way to address it. Every risk marked 'Yes' will be listed by the SC/PA on the person's ISP Risk Management Plan along with a description of what supports are available in the person's life to address it.

This document is best completed or reviewed near the time of the needs assessment as similar information is covered. However, be mindful of changing risks throughout the year. While this tool must be completed initially prior to the ISP meeting, it must also be updated throughout the year if known risks change.

The complete Risk Identification Tool is filed with the person's ISP at the CDDP or brokerage.

What to expect in your role

People with ISPs, guardians, families & friends

You can expect to be asked to share your perspective about any serious risks that you believe are present in your life.

If you are supported by a provider in a residential setting, your provider will also share information they are aware of with your SC/PA.

If you need help sharing your perspective

You or your guardian can choose someone else to help you record your perspective. Let your SC/PA know if you want help sharing your perspective.

Provider organizations & Foster providers

Familiarize yourself with the risks and risk factors in the Risk Identification Tool.

Communicate any evidence of known, serious risks promptly to the SC/PA. Maintain documentation about this communication.

If the SC/PA disagrees or does not include a risk on the ISP Risk Management Plan that you believe may be a serious risk, discuss it further with them. Provide evidence of the issue you are concerned about and document any discussions you have with the SC/PA.

Prior to the ISP meeting

You must share information with the person's SC/PA about any known, serious risks in the person's life. Talk with the SC/PA to find out the best way to share that information.

Throughout the year

Prepare and maintain a “Provider Risk Management Strategies” form specific to the location where you support the person. This should include all of the risks listed on the Provider Service Agreement or ISP Risk Management Plan that are directed to you to support.

Notify the person's SC/PA if you observe new or changing serious risks in the person's life. Identify strategies you can offer to help address these risks and discuss those strategies with the person and the SC/PA.


SC/PAs have the responsibility for the accurate completion of the Risk Identification Tool based on available information.

Complete this form based on information learned through conversations, file review and your knowledge of the person.

Upon entry into services, identify serious risks during or near the time of the needs assessment. That way, you can use the information that was discussed during the needs assessment and you don’t have to repeat conversations that may feel intrusive to the person or their family.

Continue to keep this form up-to-date throughout the year if you learn about changes in risks in the person's life.

Prior to the ISP meeting

This document must be reviewed at least annually prior to the ISP meeting.

If the person lives in his/her own home or their family home, ask the person, his/her guardian, or the people they have chosen to help plan if there are any changes in serious risks in the person's life. If you are also conducting the needs assessment for the person, check in on this information at the same time to avoid redundant conversations with the person and his/her designated representative(s).

If the person is supported by a provider in a residential setting, providers must share any updates they have about changes in risks in the person's life. Communicate with the provider to make agreements about how that information should be shared with you.

Throughout the year

Provide a copy of this tool to the person or his/her designated representative. Keep a copy of the most current Risk Identification Tool in the CDDP or brokerage files.

Familiarize yourself with the known, serious risks present in the person's life. When monitoring or checking in on the person throughout the year, listen and observe for evidence that those risks are being effectively supported.

If this document needs to be updated, you may do so by completing a change form. Other team members may also initiate a change form and send it to you for review.

Completing the form

Final responsibility for completing this document rests on the SC/PA. If the person lives in a residential setting, providers who support the person are expected to communicate any changes to this document with the SC/PA promptly.

Based on your knowledge of the person and their support needs, conversation with the person and/or their designated representative, respond to each risk by marking 'Yes', 'No', 'History', or 'SC/PA follow-up'. If you know that all risks in one section will be marked 'No', you may check the box provided to skip ahead to the next section.


Mark 'Yes' if there is evidence of the identified risk.

Expected action for SC/PA

Record the risk on the Risk Management Plan in the ISP and note how the risk is addressed.

See Risk Management Strategies for more information about addressing identified risks.


There is no available evidence of the identified risk. This response is also indicated if the person declines to discuss the issue and there is no available evidence that the risk exists.

Risks marked 'No' are not listed on the Risk Management Plan in the ISP. 


Mark 'History' if there is no available evidence of the identified risk being a current issue and supports are not needed BUT there is evidence that the identified risk did occur or needed supports within approximately the last five years.

Expected action for SC/PA

The history designation is for informational purposes only.

No risk recorded on the Risk Management Plan in the ISP. No support strategies are in place to address this issue.

Typically, if a risk is changing from Yes to History, leave it marked History for approximately five years. Circumstances may warrant changing the response from History to No in less than or more than five years. Consider if there are other documents available in the person’s file that provide information about the past issue, the person and family’s preference on how it is recorded, and the likelihood the risk will be present again.

'SC/PA follow-up'

The SC/PA may choose to mark this box to indicate an intent to follow-up on that issue.

Follow-up may be helpful if the SC/PA has reason to believe the issue may be present, but information is inconclusive or the person declines to discuss the issue.

Expected action

No risk recorded on the Risk Management Plan in the ISP. No support documents are in place to address this issue.

Expected case management actions include:

  • Note the issue and planned follow-up on the ISP, Chosen Case Management Services, as an anticipated case management service.
  • Follow-up within established timelines to see if the issue is changing or additional information becomes available.
  • Provide information about available community resources (e.g. county health department, medical professionals, etc.)  for assistance assessing or addressing the issue.
  • Document actions taken in a progress note.

There is a field provided in each section for comments. Use this space to record any useful information about why a risk was marked 'Yes', 'No', 'History', or 'SC/PA follow-up'.

Comments are considered optional and are not required.

When marking a risk 'Yes', use the comments to describe what the risk looks like for the specific person you are planning with. For example, if marking 'Yes' to the risk of Unsafe Social Behavior, describe what Unsafe Social Behavior looks for that particular person.

Avoid using the comments space to record specific support strategies for any identified risk. That information belongs in the Risk Management Plan in the ISP or in support documents prepared by a provider, such as safety plans, protocols, financial plan, etc.

Considering other supports in place

As you review each risk, think about any supports that might already be in place or that might be necessary in order to help the person be more safe around this issue. If the person relies on specific supports from someone in their life in order to avoid serious harm, mark that risk as 'Yes'. This is an important step, even if the supports currently in place are working well.

When supports are provided by a provider organization or foster provider

This additional guidance applies to #6) Unsafe Medication Management, #10) Lack of access to medical care, and #20) Safety and cleanliness of residence.

These risks do not need to be marked 'Yes' simply because the person lives in a residential setting and relies on a provider to provide basic supports with these activities of daily living. The Functional Needs Assessment identifies basic support needs in these areas. If a provider is expected to provide support around these needs, list the identified need under the appropriate service code in the Chosen Services section of the ISP.

If the only support necessary for one of these risks is provided by a provider organization or foster provider following their policies or applicable administrative rules, the risk may be marked 'No'. Consider marking 'Yes' to any of these risks if the person requires individualized supports beyond the provider’s policies or applicable administrative rules.

Considerations when planning with children
  • This tool is intended to identify risks beyond typical childhood development and parental responsibilities.
  • Do not include supports provided based on a child’s developmental level that are not as a result of the disability, such as needing to cut a child’s meat or hold a child’s hand when crossing the street.

List anyone who contributed information to assist in completing this tool. Signatures are not required on this form.

Think about who has information and who may be able to help identify known, serious risks. It may be the same people who are involved in the needs assessment. Are there others who have knowledge of the person who should be consulted? Consider family, nurses, behavior professionals, providers, etc.


The risks of aspiration, choking, dehydration, constipation, and seizures have a series of risk factors or observable symptoms listed to help identify whether a serious risk may be present. Some risk factors (e.g. letters “g”-“m” under Aspiration) may warrant additional evaluation or discussion with a qualified professional to determine the level of risk present. Unless the risk has already been determined “Yes” by a preceding risk factor (e.g. any of “a”-“f” were already marked under Aspiration), seek an evaluation to determine whether a risk is present.

If an evaluation is needed, consider professionals that are already in the person’s life. If the person has a nurse, ask the nurse for input. If the risk is related to the person's behavior and the person has a behavior consultant, start there. In addition, consider if the person has already received an evaluation from a qualified professional that is still current.

Even when an evaluation is not expected, teams can always seek an evaluation to help them rule in or rule out a risk or to get advice on the best way to support the risk.

For SC/PAs supporting people in an In-Home setting, encourage the person or family to discuss the issue with his/her primary care physician. Help them in a way that works for them to encourage follow-through. Use progress notes to indicate how follow-through is working or not working. If you have concern for the person’s immediate health and safety due to this issue and an evaluation is not available or possible, seek your supervisor’s guidance and use your professional judgment in determining whether immediate intervention is necessary.

Record information about any completed evaluations in the "Evaluations" section provided at the end of the tool.