Statewide Autism Resources and Training Project (START)

Independence Data Sheet Examples of Routines

Table of Contents

1) Responding to a text using an iPhone

2) Toileting

3) Arrival

4) Navigating the hallway- classroom to bathroom

5) Lunch

6) Completing a worksheet

7) Following a visual schedule when making transitions

8) Buying food from a concession stand

9) Getting a book from the library

STUDENT INDEPENDENCE DATA

Student Name: __Adriana___Martinez________ Observer 1: __Mrs. Trimmins________________

Class/Teacher: _____Mrs. Trimmins_______________ Observer 2: ________________ IOA: ______

Routine: ______Responding to a text using an iPhone___________________

KEY (definitions on back): 4=Independent 3=Visual / Gestural 2=Verbal 1=Partial or Full Physical S=Step not completed by student

Steps of Routine Date

1. When received a text message and it’s appropriate to text, tap circle button on bottom of the phone to turn on screen

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2. Locate message icon, and tap 4321S

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3. Tap on the new text message (indicated by blue circle)

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4. Read text message 4321S

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5. Taps on box that states “text message”

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6. Types an age appropriate, relevant reply to text message by tapping the phone keyboard

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7. When done typing message, taps “send”

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8. 4321S

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STUDENT INDEPENDENCE DATA

Student Name: __Adriana___Martinez________ Observer 1: __Mrs. Trimmins________________

Class/Teacher: _____Mrs. Trimmins_______________ Observer 2: ________________ IOA: ______

Routine: ______Toileting___________________

KEY (definitions on back): 4=Independent 3=Visual / Gestural 2=Verbal 1=Partial or Full Physical S=Step not completed by student

Steps of Routine Date

1. Walk into bathroom stall 4321S

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2. Pull pants down 4321S

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3. Sit down/Stand 4321S

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4. Eliminate in toilet 4321S

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5. Wipe (if applicable) 4321S

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6. Pull pants up 4321S

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7. Zip or button pants (if applicable) 4321S

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8. Flush 4321S

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9. Wash hands 4321S

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STUDENT INDEPENDENCE DATA

Student Name: __Adriana___Martinez________ Observer 1: __Mrs. Trimmins________________

Class/Teacher: _____Mrs. Trimmins_______________ Observer 2: ________________ IOA: ______

Routine: ______Toileting___________________

KEY (definitions on back): 4= Independent 3=Visual / Gestural 2=Verbal 1=Partial or Full Physical S=Step not completed by student

Steps of Routine Date

1. Walks off bus with belongings and enters correct door

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2. Walks to correct locker 4321S

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3. Puts away belongings in locker 4321S

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4. Pulls out items needed for class from backpack

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5. Hold items needed for class in one hand/arm and closes locker with the other hand/arm

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6. Walks to correct class 4321S

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7. Takes a seat and puts item on top of desk

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STUDENT INDEPENDENCE DATA

Student Name: __Adriana___Martinez________ Observer 1: __Mrs. Trimmins________________

Class/Teacher: _____Mrs. Trimmins_______________ Observer 2: ________________ IOA: ______

Routine: ______Navigating the hallway- classroom to bathroom___________________

KEY (definitions on back): 4=Independent 3=Visual / Gestural 2=Verbal 1=Partial or Full Physical S=Step not completed by student

Steps of Routine Date

1. Asks permission to go to the bathroom

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2. Once given permission, quietly gets up from seat and walks to the classroom door

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3. Turns in the direction towards to bathroom

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4. Walks straight to the bathroom 4321S

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5. Enters into the bathroom and completes bathroom routine

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6. Leaves bathroom and turns in direction towards the classroom

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7. Walks straight to the classroom 4321S

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8. Walks into classroom 4321S

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9. Quietly walks to seat and sits down 4321S

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STUDENT INDEPENDENCE DATA

Student Name: __Adriana___Martinez________ Observer 1: __Mrs. Trimmins________________

Class/Teacher: _____Mrs. Trimmins_______________ Observer 2: ________________ IOA: ______

Routine: ______Completing a worksheet___________________

KEY (definitions on back): 4=Independent 3=Visual / Gestural 2=Verbal 1=Partial or Full Physical S=Step not completed by student

Steps of Routine Date

1. Walk to locker and grab lunch 4321S

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2. Walk to lunchroom 4321S

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3. Walk to table and sit down 4321S

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4. Open lunch bag 4321S

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5. Remove items from lunch bag and place on table

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6. Open containers and eat food 4321S

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7. Take drinks of beverage throughout meal

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8. When finished (or told it is time to finish to), clean up

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9. Walk to garbage can and throw away trash

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10. Walk back to locker and put lunch inside

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STUDENT INDEPENDENCE DATA

Student Name: __Adriana___Martinez________ Observer 1: __Mrs. Trimmins________________

Class/Teacher: _____Mrs. Trimmins_______________ Observer 2: ________________ IOA: ______

Routine: ______Completing a worksheet___________________

KEY (definitions on back): 4=Independent 3=Visual / Gestural 2=Verbal 1=Partial or Full Physical S=Step not completed by student

Steps of Routine Date

1. Grab correct worksheet and walk to seat

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2. Place worksheet on table 4321S

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3. Pull out pencil 4321S

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4. Write name on worksheet in the designated spot

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5. Read the instructions 4321S

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6. If instructions are not clear or have difficulty reading instructions, raise hand to ask for help and asks for help

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7. Follow instructions to complete worksheet

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8. When needed, asks for help 4321S

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9. When completed, take worksheet to designated spot for completed work.

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STUDENT INDEPENDENCE DATA

Student Name: __Adriana___Martinez________ Observer 1: __Mrs. Trimmins________________

Class/Teacher: _____Mrs. Trimmins_______________ Observer 2: ________________ IOA: ______

Routine: ______Following a visual schedule when making transitions___________________

KEY (definitions on back): 4=Independent 3=Visual / Gestural 2=Verbal 1=Partial or Full Physical S=Step not completed by student

Steps of Routine Date

1. When the bell rings, pull out visual schedule

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2. Move current icon on the schedule to the completed section

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3. Look at next icon on schedule 4321S

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4. Walk to next activity 4321S

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5. Put visual schedule away 4321S

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6. Wait for instructions or if previously told to, start on next activity

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7. 4321S

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8. 4321S

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STUDENT INDEPENDENCE DATA

Student Name: __Adriana___Martinez________ Observer 1: __Mrs. Trimmins________________

Class/Teacher: _____Mrs. Trimmins_______________ Observer 2: ________________ IOA: ______

Routine: ______Buying food at a concession stand___________________

KEY (definitions on back): 4=Independent 3=Visual / Gestural 2=Verbal 1=Partial or Full Physical S=Step not completed by student

Steps of Routine Date

Stand behind the last person in line 4321S

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While in line, look at menu or items on display to determine what to buy based on how much money he or she has to spend

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When asked something like, “What do you want? How can I help you? What can I get you?" Responds by clearly stating desired item(s)

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When told the cost of the item, gives enough money to cover the cost

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Checks change to make sure it is correct 4321S

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Puts change back in wallet, pocket, and/or purse

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Grabs desired item(s) 4321S

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Gets out of line 4321S

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STUDENT INDEPENDENCE DATA

Student Name: __Adriana___Martinez________ Observer 1: __Mrs. Trimmins________________

Class/Teacher: _____Mrs. Trimmins_______________ Observer 2: ________________ IOA: ______

Routine: ______Getting a book from the library___________________

KEY (definitions on back): 4=Independent 3=Visual / Gestural 2=Verbal 1=Partial or Full Physical S=Step not completed by student

Steps of Routine Date

1. Go to computer 4321S

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2. Click on “key word” drop down menu and select: keyword, author, title, or subject

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3. Click on “locations” drop down menu and select current library location

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4. Click on empty box between the two drop down menus

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5. Type in words that correspond with selected menu item (e.g. if title is selected, types in title)

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6. Click on the submit button 4321S

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7. Click on the correct book 4321S

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8. Write down Call number 4321S

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9. Walk to designated section and find book using call number

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