Reis Forms

RESIDENTIAL ENVIRONMENT IMPACT SURVEY (REIS)
Date: _____________ Evaluator: ____________________________ Residence: _____________________________
I. Walk Through Observation Guide

Access to space:
Accessibility throughout the home
Availability/accessibility of space for activity of participants choice (kitchen, laundry)
Cognitive and physical supports:

Cognitive supports include photos, reminder systems, posted schedule, checklists, etc.
Physical supports include grab bars, stair railings, adaptive equipment
Physical Environment:
Barriers inside and outside the home (presence of stairs and railing, clutter, crowdedness)
Adequate lighting
Width of doorways, ease of use of doorknobs or handles, doors easy to open, light switches within
reach
Bathroom accessibility: toilet height, grab bars for toilet and tub, sink
Natural Environment:
Accessibility and condition of the yard outside the home
Furniture:
Degree to which furniture matches capabilities of participants (chairs/sofa easy to get on and off,
comfortable)
Safety concerns (bathroom, throw rugs, carpeting)
Fisher, G., Arriaga, P., Less, C., Lee, J. & Ashpole, E. REIS Version 2.0, August 2008
Duplication of this instrument is permitted by the Model of Human Occupation Clearinghouse, www.moho.uic.edu

I. Walk Through Observation Guide (cont)

Sensory Environment:
Presence of extreme temperatures, noxious odors, visual or auditory distractions, noise level
Opportunity to modify sensory qualities of the environment to the extent desired
Availability of sensory input (rocking chair)
Availability of quiet space
Homelike Qualities:
Home dcor, does it reflect personal interests
Dcor, food and music, does it reflect the culture of the participants
Presence of pictures on the walls
Quality of furniture, typical of what is found in a home
Presence of objects:
Objects present for activities that the residents may have a desire to do, such as books, movies,
exercise equipment, computer, and crafts
Observe for the use of mobility aids or adaptive equipment
Personal Preferences:
Degree to which the environment seems to support the exploration of interests, social relationships,
personal preferences and decision-making

I. Walk Through Observation Guide (cont)

Schedule:
Daily schedule
How duties/responsibilities are allotted and communicated
Opportunities to deviate from set routine
Impact of routine on life/functioning inside the home
Interaction with Others in the Home and Family/Friends:

Behaviors, attitudes, or emotions expressed towards each other
Social network outside the home
Problem resolution
Nature of interaction among participants in the home
Interaction with Staff:

Nature of interaction with participants (maternal, neutral, authoritative, paternal)
Behaviors, attitudes, or emotions expressed towards participants
Problem resolution
Decision making process
Support for autonomy and empowerment

IIa. Guide for Observation of Activities/Tasks

It is suggested that three activities be observed. This should include one mealtime, one transition
time (morning routine or bedtime routine), and one group activity, either a community meeting or a
leisure/recreation activity.
Activity Observed:
Participants and Staff Present:
Nature of Interactions:
Participant-Participant:
Participant-Staff:
Staff and Environmental Support:
Type(s) of support provided
How is support provided?
Is the level of support appropriate?
Is the level of support desired by the resident(s)?
Additional Comments:

IIb. Guide for Observation of Activities/Tasks

Activity Observed:
Participant-Staff:

IIc. Guide for Observation of Activities/Tasks

Activity Observed:
Participant-Staff:

III.a: SPACE
Information Obtained Via Group Interview of Participants/Residents
Listed below are places in and around the home environment. For each
statement, mark how the residents respond when questioned about whether they
have access to be in and use the space.
Not
Sometimes
Always
accessible
accessible
accessible
Physical Spaces
Bedroom
Kitchen
Laundry room
Living room
Bathroom
Storage area for personal items
(clothes, money, grooming items)
such as closets, drawers, or
containers
Place to be alone
Place for interaction with others
(housemates, guests)
Natural environment
Yard
Safe place to walk around outside
the home
Next, for items that are not always

accessible, mark how important
accessibility is to the residents.
Important
Not important
Add any additional comments in this

section.
Comments
Additional questions:
Is there a quiet space available if it gets noisy?
Do you feel the home is comfortable?
Do you feel safe living here?

III.a: SPACE (cont)
Listed below are features of the environment. For each statement,

mark how the residents respond when questioned about whether these
features are a problem.
No problem
This is a
problem
Physical Environment
Stairs outside home
Stairs inside home
Type of furniture
Amount of furniture in room
Amount of clutter (a lot of objects
in the home)
Add any additional comments in this section.
Comments (describe the problem and the limit/barrier that it presents)
Are there any things about the home like temperature, noise, lighting, smell that affect you, or that bother you?
Are you allowed to change the temperature, lighting, and noise level when you want?
How important is this to you?
Is the home easy to move around in? (Getting around in the kitchen, living room, bedroom, bathroom, other rooms, opening doors, getting
through doorways.) (Note if anyone in the home has a mobility impairment and/or if anyone uses any assistive device such as a cane, walker,
or wheelchair).
Is the bathroom easy to use and does it feel safe? ( Getting on and off the toilet and in and out of the tub/shower)

III.b: OBJECTS
Below is a list of personal objects that may or may not be found in the
residential home. For each object check whether it is readily available to the
participants or not available to them.
Object
Not
Available
Available
Next, for objects that are not

available, check whether each
object is important to the
interviewees (optional section).
. Check if
object was
observed in
the home.
Not Important
Yes
Important
No
Add any additional

comments in this section
Comments
Activities of Daily Living (ADL)

Grooming Supplies/Makeup (shampoo, soap,
deodorant, feminine products)
Grooming Tools (razor, toothbrush, nail clippers)
Clothing
Adaptive equipment: special eating utensils, dressing
aids.
Leisure/Recreation
Your own television
Your own VCR/DVD player and videos/DVDs
Your own music player or radio
Your own materials for your hobbies, like art & craft
supplies (paints, markers, paper, scissors, glue, yarn,
craft kits), gardening tools, camera (if relevant)
Your own educational materials (worksheets, pencils,
workbooks, textbooks)
Your own money
Your own books
Your own photographs
Your own stuff
Other: ______________________________________
____________________________________________
Was there anything I didnt ask you about that is important to you?
Are there things you dont have in the home that you would like to have, if possible?

III.c: TASKS/ ACTIVITIES
Below are activities that the participants may or may not do. For each activity check whether or
not they do the activity. If the activity is not applicable to the home, check Not Applicable (N/A).
If they dont do the activity, note the reason.
Activity
N/A
Do you do
If you dont do the activity, are
the activity?
you interested in doing it?
Y
N
Y
N
If you are interested in doing the activity, but youre not

doing it, what is stopping you from doing the activity?
Activities of Daily Living (ADL)

Feeding yourself
Dressing yourself
Bathing/Showering yourself
Using the toilet yourself
Grooming yourself (shaving, brush
teeth, nail care, makeup)
Instrumental Activities of Daily
Living (IADL)
Using the telephone to make or receive
calls
Spending my money on what I want
Taking medication
Shopping
Cooking/Baking
Exercising
Taking care of a pet
Work/School/Chores
Going to work or to a work program
Going to a day program
Going to school or job training program
Going to a volunteer job
Doing household chores (cleaning,
laundry)
Doing yardwork/gardening
Leisure/Recreation
Drawing/Painting
Sewing/crafts/knitting
Reading
Taking pictures
Home decorating
Watching TV/movie
10

Below are activities that the participants may or may not do. For each activity check whether or
not they do the activity. If the activity is not applicable to the home, check Not Applicable (N/A).
If they dont do the activity, note the reason.
Activity
N/A
Do you do
If you dont do the activity, are
the activity?
you interested in doing it?
Y
N
Y
N
If you are interested in doing the activity, but youre not

doing it, what is stopping you from doing the activity?
Leisure/Recreation (cont)
Using the computer (games, email,
web)
Writing (poems, stories, journaling)
Planning for parties/events in the home
Attending parties/events in the home
Dancing
Singing
Listening to music
Playing board games or cards
Playing a sport
Walking in the neighborhood for
pleasure/exercise
Visiting family inside the home
Visiting friends inside the home
Community Activities
Going to the park, fitness center,
YMCA, or other fitness facility
Going on trips/traveling
Using public transportation/ paratransit
Going to the movies
Going to the library
Going to community events (sporting
events, plays, concerts)
Going to a restaurant
Going on dates
Going to church or temple
Other things not listed
Other: _________________
Other: _________________
Other: _________________
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III.c: TASKS / ACTIVITIES (cont)
Which activities that youre not doing would you MOST like to do, if possible?
Can you suggest some changes to allow you to do the activities that you like more often?
Do you feel you get enough help to do the things that weve just been talking about? If not, what do you think you need more help to do?
Do you feel that the staff ever give you too much help or watch over you too closely?
12

III.d: SOCIAL GROUPS/SOCIAL ENVIRONMENT
Below are decisions that are made in the environment. For each statement, indicate how these
decisions are made. If decisions are made by a person other than staff, indicate if it is parent, peer,
etc.
Next, for each item where

someone else decides, is
that a decision that the
residents would like to
make themselves?
Add any additional comments in

this section.
No
Comments
Who makes the decision?

Decision
Individual
resident s
decision
Group
decision
by the
residents
Staff &
resident
decide
together
Staff or
other
persons
decision
If others
decision,
indicate
who it is.
Yes
Personal Preferences
Arrange & decorate your own room
Arrange & decorate common areas
What clothes to wear
What to listen to on the radio
What to watch on TV and when
What to spend money on and when
What to eat for meals and when
Where to put money, clothing,
grooming products
Schedule/Routine
What time to wake up & go to sleep
What is done after work
How to spend free time
When and how chores are done
When to take showers/baths
When phone calls are made &
received
When visitors are allowed
What to do with visitors
Social policies
How roommates are put together
How rooms are assigned
Who goes on outings
Where to go on outings
Who can leave the home and when
In general, how rules and decisions
are made about how things go
13

III.d: SOCIAL GROUPS/SOCIAL ENVIRONMENT (cont)
Routine
Describe your daily routine, from the time you wake up until the time you go to sleep. Is this the way you like it?
Do you have enough time to do what you want, enough free time?
If you could change anything about your day, what would it be?
Social Interaction with housemates, family and friends

Do you have friends outside the home? How often do you call them? Do you visit them or do they come visit you?
Do you talk to your neighbors?
Do you have contact with your family?
Do you get along with everyone in your home?
Do you ever have a disagreement with someone in your home? What happens when there is a disagreement?
What is it like during mealtimes? Do people talk with each other? (Staff and residents, residents and residents)
How often? Do you visit them or do they come visit you?
14

III.d: SOCIAL GROUPS/SOCIAL ENVIRONMENT (cont)
Social Interaction with Staff

How do you get along with staff?
Are staff members available when you want to talk?
Policies/Rules
What are the rules in your home?
Are there rules that you think should be changed? (You may want to include a disclaimer that the evaluator does not have the power to change
the rules but can convey the desire for the rules to be changed)
Do you ever go out of the home on your own? Do you decide where you want to go?
If you dont ever go out, why not? (dont want to, never did it before, want to but it is not allowed)
Placement in Home
How was it decided that you would live here?
Is this where you want to live and why?
15

Name of person interviewed: ____________________________ How long employed in this residence? _________________
Job title (manager, supervisor, direct care staff [days], direct care staff [weekends], etc.) ____________________________
IV. Supervisor/Staff Interview

As you know we are trying to come up with suggestions to improve your home. Ive observed a lot and gotten
input from the participants. I would now like to get your perspective.
1. Ive gathered information from the participants about how decisions are made in the home. Id like to get
your perspective also. Do the participants have the opportunity to participate in decisions about things in
the home? Can you give me an example of a decision the participants helped to make? (For example,
who makes decisions about how to arrange and decorate common areas? Who makes decisions about
when residents go to sleep?)
2. How do the participants get along with staff? How do the participants get along with each other?
3. How much help is needed by the participants as a whole with the different things that they do (e.g. selfcare, chores, leisure activities, community trips, communication/interaction)? Do you feel the participants
get the right amount of help? If not, why not and which situations/activities are the most difficult to provide
the right amount of help?
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4. How are difficult behaviors by the participants handled? What type of difficult behaviors are the hardest
for the staff to handle?
5. Do you feel you and the staff need additional knowledge and skills to provide the right kind of help to the
participants? What types of educational programs or experiences should be provided to staff?
6. Do you feel that communication is good between the home and the day programs and between the home
and the families? What could be done to improve this?
7. How are goals determined? Do you feel they are useful? How could this process be improved?
17

8. Does the staff select activities that are aimed at helping participants meet their goals? How could this be
improved?
9. What does the staff do to support self-advocacy and empowerment of the participants? For example, are
they involved in peer advocacy groups, do they learn how to make decisions, do they learn to speak up for
themselves and their needs?
10. In summary, what do you think the home does well?
11. What areas do you think need improvement? What are the barriers to improvement (such as
administrative support, governmental policies, budget limitations)? What changes would you suggest?
Thank you so much for your help. I will get back to you to summarize what I learned and my recommendations.
18

Each item below refers to an aspect of the residential environment and is scored using a 4-point scale. Your rating should reflect how each aspect of the environment meets the
needs and desires of the residents, and the extent to which the appropriate level of support and opportunity is provided.
Strength
Appropriate
Needs some improvement
Needs major improvement
NR
N/A
Not rated
Not applicable
Evaluator:
This environmental aspect is a strength of the residential setting and provides all of the residents with exceptional opportunities
and support.
This environmental aspect provides appropriate support and opportunities for the residents in the residential setting.
Some improvement is needed for this environmental aspect to provide appropriate support and opportunities for the residents
in the residential setting.
Major improvement is needed so that this environmental aspect can provide support and opportunities for the residents in the
residential setting.
Not rated, not enough information to rate this item
This item does not apply to this residential setting
Home Coordinator/Supervisor:
Residents participating:
Date(s):
Name/type of home:
Staff participating:
Address of home:
1. Access to Space: The extent to which physical space provides appropriate accessibility and meets the needs/desires of
the residents
NR
N/A
NR
N/A
NR
N/A
NR
N/A
NR
N/A
NR
N/A
NR
N/A
NR
N/A
NR
N/A
Comments:
2. Natural Environment: The extent to which the area around the home provides appropriate accessibility and meets the
needs/desires of the residents
Comments:
3. Physical Environment: The extent to which the physical environment is barrier-free and facilitory of independence and
safety
Comments:
4. Sensory Environment: The extent to which sensory conditions and opportunities in the home are appropriate and meet
the needs/desires of the residents
Comments:
5. Homelike Qualities: The extent to which the home is comfortable, homelike, culturally appropriate, and a welcoming
environment.
Comments:
6. ADL Objects: The extent to which objects for activities of daily living are available and the support provided for their use is
appropriate
Comments:
7. Leisure Objects: The extent to which leisure objects are available and the support provided for their use is appropriate
Comments:
8. Adaptive Equipment: The extent to which appropriate and necessary adaptive equipment is provided and support
provided for its use is appropriate
Comments:
9. Participation in ADL: The extent to which there are opportunities and resources for the residents to participate in
performing activities of daily living (eating, dressing, bathing, grooming)
Comments:
19

10. Participation in Work and Chores: The extent to which there are opportunities and resources for the residents to
participate in performing work and chores to the extent they desire
NR
N/A
NR
N/A
NR
N/A
NR
N/A
NR
N/A
NR
N/A
NR
N/A
NR
N/A
NR
N/A
NR
N/A
NR
N/A
NR
N/A
NR
N/A
NR
N/A
NR
N/A
Comments:
11. Participation in IADL: The extent to which there are opportunities and resources for the residents to participate in
performing instrumental activities of daily living (cooking, laundry, managing finances, shopping, use of the phone, computer)
Comments:
12. Participation in Leisure/Recreational Activities: The extent to which there are opportunities and resources for the
residents to participate in leisure activities
Comments:
13. Community Activities: The extent to which there are opportunities and resources for the residents to participate in
events and outings in the community
Comments:
14. Self-Expression: The extent to which there are opportunities and resources for the residents to participate in expressing
themselves via decorating personal space, clothing choice, and choice of how to spend time
Comments:
15. Schedule/Routine: The extent to which the schedule and routine facilitates maximum participation and independence
Comments:
16. Interactions with Others Living in the Home, Family and Friends: The extent to which there are opportunities and
resources for the residents to interact with others
Comments:
17. Interactions with Staff: The extent to which interactions with staff are positive and appropriate
Comments:
18. Decision Making: The extent to which there are opportunities and resources for residents to participate in decisions that
impact on life in the home (policies, rules, routines, privileges)
Comments:
19. Level of Assistance Provided: The extent to which the level of assistance provided to residents by staff is appropriate,
desired, and supports maximum participation
Comments:
20. Autonomy: The extent to which opportunities for autonomy and independence meet the needs and desires of the
participants
Comments:
21. Empowerment: The extent to which residents are provided with appropriate opportunities and resources to identify and
pursue the things that are most important to them, make informed decisions of consequence, and advocate for themselves
Comments:
22. The Goal Process: The extent to which the goals established for the residents provide an appropriate and useful
measure of potential achievement and progress
Comments:
23. Outside Communication: The extent to which communication with the day program/work center and family is wellcoordinated and supports the full participation of the residents in home, day program, and family activities
Comments:
24. Occupational Identity and Role Development: The extent to which residents are provided with appropriate
opportunities and resources to develop a positive and meaningful occupational identity and roles
Comments:
20

RECOMMENDATION FORM
Evaluator:
Date:
Name/address of residence:
Coordinator/Supervisor of residence:
Priority
Recommendations for Administration:
Possible strategies:
Recommendations for Coordinator/Supervisor:
Recommendations for others (QMRP, consulting psychologist, social worker):
Recommendations for Direct Care Staff:
Recommendations for Residents:
Fisher, G., Arriaga, P., Less, C., Lee, J. & Ashpole, E. REIS Version 2.0, October 2008
21

To be completed by responsible staff/administration (Names: _____________________________)
Response/Comments:
Plan/Timeline:
Fisher, G., Arriaga, P., Less, C., Lee, J. & Ashpole, E. REIS Version 2.0, October 2008
22

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RESIDENTIAL ENVIRONMENT IMPACT SURVEY (REIS)

Date: _____________ Evaluator: ____________________________ Residence: _____________________________

I. Walk Through Observation Guide

Availability/accessibility of space for activity of participants choice (kitchen, laundry)

Cognitive and physical supports:

Physical supports include grab bars, stair railings, adaptive equipment

Safety concerns (bathroom, throw rugs, carpeting)

RESIDENTIAL ENVIRONMENT IMPACT SURVEY (REIS)

I. Walk Through Observation Guide (cont)

Opportunity to modify sensory qualities of the environment to the extent desired

Availability of sensory input (rocking chair)

Availability of quiet space

Presence of pictures on the walls

Quality of furniture, typical of what is found in a home

Observe for the use of mobility aids or adaptive equipment

RESIDENTIAL ENVIRONMENT IMPACT SURVEY (REIS)

I. Walk Through Observation Guide (cont)

How duties/responsibilities are allotted and communicated

Opportunities to deviate from set routine

Impact of routine on life/functioning inside the home

Interaction with Others in the Home and Family/Friends:

Social network outside the home

Nature of interaction among participants in the home

Interaction with Staff:

Behaviors, attitudes, or emotions expressed towards participants

Decision making process

Support for autonomy and empowerment

RESIDENTIAL ENVIRONMENT IMPACT SURVEY (REIS)

IIa. Guide for Observation of Activities/Tasks

Participants and Staff Present:

Staff and Environmental Support:

Type(s) of support provided

How is support provided?

Is the level of support appropriate?

Is the level of support desired by the resident(s)?

RESIDENTIAL ENVIRONMENT IMPACT SURVEY (REIS)

IIb. Guide for Observation of Activities/Tasks

Participants and Staff Present:

Staff and Environmental Support:

Type(s) of support provided

How is support provided?

Is the level of support appropriate?

Is the level of support desired by the resident(s)?

RESIDENTIAL ENVIRONMENT IMPACT SURVEY (REIS)

IIc. Guide for Observation of Activities/Tasks

Participants and Staff Present:

Staff and Environmental Support:

Type(s) of support provided

How is support provided?

Is the level of support appropriate?

Is the level of support desired by the resident(s)?

RESIDENTIAL ENVIRONMENT IMPACT SURVEY (REIS)

Information Obtained Via Group Interview of Participants/Residents

Next, for items that are not always

Add any additional comments in this

Do you feel the home is comfortable?

Do you feel safe living here?

RESIDENTIAL ENVIRONMENT IMPACT SURVEY (REIS)

III.a: SPACE (cont)

Date: _ Evaluator: Residence: _____________