Community  Choices Waiver
                                   Participant-Directed Personal Support Services: Monthly Budget Calculator  
         Participant Name:                                              Purpose:                                          Date:
             Medicaid ID:                                         Plan Start Date:                    Plan End Date: 
                          Activity                                        Comments                      Minutes Per  Days Per  Total 15 Minute  Total 15 minute 
                                                                                                            Day        Week     units Per Week  units/month
    Eating: Assistance with using suitable utensils to bring food to 
    the mouth, as well as the ability to chew and swallow the food                                                                                      -                               -   
    once the meal is presented in the customary manner.
    Bathing: Assistance with washing, rinsing, and drying the body 
    in either a tub, shower, or sponge/bed bath.                                                                                                        -                               -   
    Dressing: Hands-on or stand-by assistance with dressing and 
    undressing.                                                                                                                                         -                               -   
    Grooming: Assistance with oral care, hair grooming (combing 
    or brushing), nail care, skin care, and shaving the face or 
    applying makeup.
      Oral Care: Assistance with brushing and flossing teeth, 
      cleaning dentures, and gum/mouth care.                                                                                                            -                               -   
      Hair Grooming: Assistance with combing, brushing, and 
      basic styling of the hair.                                                                                                                        -                               -   
      Nail Care: Assistance with soaking, filing, and trimming 
      finger and toenails.                                                                                                                              -                               -   
      Skin Care: Assistance with preventative skin care, including 
      application of lotions, sprays, or solutions and monitoring for                                                                                   -                               -   
      skin changes. 
      Shaving/Applying Makeup: Shaving the face with an 
      electric or safety razor or basic makeup styling.                                                                                                 -                               -   
    Toileting: Assistance with maintaining perineal hygiene and 
    adjusting clothing before and after using a toilet, commode, 
    bedpan, or urinal; changing incontinence clothing or pads;                                                                                          -                               -   
    emptying Foley or suprapubic catheter bags (no disruption of 
    the closed system); and emptying ostomy bags. 
    CCW02 - Participant-Directed Budget Calculator - Updated 5/2022
    Functional Mobility: Assistance with moving between 
    locations or with changing and controlling body position. 
    Includes assistance with walking, getting in and out of bed, and                                                                                      -                               -   
    getting into and out of a chair/wheelchair.
    General Household Tasks: Assistance with light 
    housekeeping, grocery and personal needs shopping,and meal 
    preparation. These activities are specifc to the participant and 
    must not include time for tasks related to other household 
    members. 
       Light Housekeeping: Assistance with cleaning only the 
       rooms/spaces accessed and used by the participant on a 
       regular basis. This includes general cleaning tasks such as 
       sweeping/mopping/vacuuming floors; cleaning/disinfecting                                                                                           -                               -   
       bathroom surfaces; washing, drying and folding the 
       participant’s laundry; and washing the participant’s dishes. 
       Shopping: Shopping for groceries and personal needs 
       items necessary for the participant.                                                                                                               -                               -   
       Meal Preparation: Preparing and cooking basic meals and 
       snacks.                                                                                                                                            -                               -   
    Employee Training and Performance Management: 
    Completing the required curriculum and any additional training 
    on the participant’s specific needs. Also includes participating in 
    performance evaluation and management activities. 
                                                                                                                 Number of Service Units Per Month                            -   
                                                                                                                           Monthly Budget Amount           $0.00
    CCW02 - Participant-Directed Budget Calculator - Updated 5/2022