mansef functional career development portfolio
TRANSCRIPT
MANSEF Functional
Career Development
Portfolio Counseling & Advisory Activities
Developed by
Amy Alvord, The Ivymount School
Dareen Barrios, Maryland School for the Blind
Sue Bennett, Bendictine School
Kelly Gealy, Maryland School for the Blind
Joshua Gervais, St. Elizabeth School
Sarah Martin, St. Elizabeth School
Sharon Nickolaus, The Ivymount School
David Quinn, Benedictine School
Valerie Smitheman-Brown, Kennedy Krieger LEAP Program
Resources gathered from:
Career and Technology Education, Maryland State Department of Education
Center for Career Development, Maine Community Colleges
Florida Department of Education
MANSEF Personnel
Office of Career and Technology Education, South Dakota State Department of
Education
About My Child… .............................................................................................................. 4
Things to Think About… .................................................................................................... 6
Student Profile .................................................................................................................... 7
Community Mobility Skills Profile .................................................................................. 23
Sample Student Interview Form ....................................................................................... 26
Vocational Critical Skills Checklist .................................................................................. 29
VOCATIONAL POINT SHEET ...................................................................................... 30
VOCATIONAL POINT SHEET II .................................................................................. 31
Work Card ......................................................................................................................... 32
Career Portfolio ................................................................................................................. 34
CAREER EXPLORATION ACTIVITY .......................................................................... 35
Future Planning Inventory ................................................................................................ 36
How Did My IEP Meeting Go .......................................................................................... 42
IEP Invite to Student ......................................................................................................... 46
IEP/Transition Meeting Checklist.................................................................................... 47
List of Rating Scales and Inventories ............................................................................... 48
Personal Goals for Transition ........................................................................................... 49
Personal Information ......................................................................................................... 51
Planning for the Future ..................................................................................................... 52
Preparing for My IEP Meeting ......................................................................................... 59
Student Letter of Invitation to IEP Meeting ..................................................................... 61
Student Preferences ........................................................................................................... 62
Student Skills and Abilities ............................................................................................... 66
SUMMARY OF SELF-AWARENESS INVENTORIES CAREER EDUCATION ....... 89
Things that are Important to Me ....................................................................................... 91
Transition Interview Questions ......................................................................................... 93
SURVEY OF INDOOR AND OUTDOOR RECREATIONAL ACTIVITIES ............... 96
FAMLY INTERVIEW FORM ......................................................................................... 99
Functional Life Plan-Staff Questionnaire ....................................................................... 114
Functional Life Plan Process .......................................................................................... 115
PARENT SURVEY ........................................................................................................ 121
Student Dream Sheet....................................................................................................... 123
Preferences and Interests................................................................................................. 126
Functional Life Plan-Parent Questionnaire ..................................................................... 127
Transition Services-Parent/Guardian Questionnaire ....................................................... 128
COURSE OF STUDY PLAN ......................................................................................... 131
FUNCTIONAL CAREER DEVELOPMENT PORTFOLIO ......................................... 132
PROGRAM FOR TRANSITION-PARENT SURVEY ................................................. 133
Career Cluster Collage .................................................................................................... 135
CAREER CLUSTER DESCRIPTIONS ......................................................................... 136
TRANSITION CAREER CLUSTERS ........................................................................... 138
REVIEW OF SKILLS CHECKLISTS ........................................................................... 140
INITIAL TRANSITION PLANNING ........................................................................... 141
Fine Motor/ Eye Hand Integration .................................................................................. 142
Imitation .......................................................................................................................... 143
Group Skills .................................................................................................................... 145
Social............................................................................................................................... 147
Cognitive/Readiness Skills ............................................................................................. 150
Expressive Communication ............................................................................................ 155
READINESS SKILLS CHECKLIST ............................................................................. 159
READINESS SKILLS CHECKLIST II ....................................................................... 161
READINESS SKILLS CHECKLIST III ....................................................................... 163
READINESS SKILLS CHECKLIST IV ...................................................................... 165
Interview Questions ........................................................................................................ 167
GROUP SKILLS CHECKLIST ..................................................................................... 169
SOCIAL SKILLS CHECKLIST..................................................................................... 171
VOCATIONAL SKILLS CHECKLIST ......................................................................... 173
School Based (C) 8, 9, 10, 11, 12 (Circle One)
Student: ________________________________________________
About My Child…
Parents, please take a few moments to think about your child and answer these questions.
Describe your child:____________________________
___________________________________________
___________________________________________
___________________________________________
___________________________________________
What are your dreams for your child?
(List them no matter how big they are.) _____________
___________________________________________
___________________________________________
___________________________________________
___________________________________________
What are your fears for your child? _______________
___________________________________________
___________________________________________
___________________________________________
___________________________________________
What are your child’s strengths? __________________
___________________________________________
___________________________________________
___________________________________________
___________________________________________
___________________________________________
What are your child’s needs? _____________________
School Based (C) 8, 9, 10, 11, 12 (Circle One)
Student: ________________________________________________
___________________________________________
___________________________________________
___________________________________________
___________________________________________
List at least three things you would like your child to
work on during the upcoming school year:
1. _________________________________________
_________________________________________
2. _________________________________________
_________________________________________
3. _________________________________________
_________________________________________
“Let not our needs determine our dreams…
but let our dreams determine our needs.” Colleen F. Tomke
Keep the focus of your vision on your child’s strengths
and interests. Think about the things in life that you value and
would like your child to have. Most people value their
relationships with others and being an active member of society.
We also tend to value being able to pursue things we are good at
and using them for something meaningful and purposeful.
School Based (C) 8, 9, 10, 11, 12 (Circle One)
Student: ________________________________________________
Things to Think About…
Please mark all areas of interest or concern. LIFE SKILLS
Using basic appliances & tools
Maintaining house and grounds
Fitness/wellness/nutrition
Appropriate dress
Personal hygiene/grooming
Social skills
Safety
Sex education
Marriage, children, parenting
Preparing & consuming food
Care of clothing
Laundering of clothing
Household cleaning
Shopping
Money management
Care of medical condition
Other _____________________
SOCIAL SKILLS Handling praise & critcism
Knowledge of physical self
Self-confidence
Aware of emotions
Respect for others
Respect for authority
Appropriate behavior in public
Honesty
Developing friendships
Listening & responding
Other _____________________
HOUSING OPTIONS Live Alone Live with roommate Live with existing family Live with other family member Apartment House Supervised apartment/house Host home Group Home Other _____________________
CAREER/EMPOYMENT Full/Part-time regular job
(Competitive Employment) Full/Part-time (Supported Employment)
Self Employment Volunteer Work Sheltered Workshop Military Service Other _____________________
EMPLOYMENT DEVELOPMENT Awareness of job possibilities
Understanding personal strengths
& areas I need to work on
Being mindful of work habits
Appropriate behaviors
Finding & keeping a job
Knowing appropriate dress
Other _____________________
Counseling & Advising (A) 8, 9, 10, 11, 12 (Circle one)
Maryland School for the Blind Career Education Program
Student Profile Update: 10/6/05
To be completed by: CEP Staff Frequency & Timeframe: Initial Intake to CEP, then updated annually
Student Name: First, Middle and Last
Date Completed:
Age of Student: Age 14
Age 15
Age 16
Age 17
Age 18
Age 19
Age 20
Age 21
Completed by:
Personal Information
Demographics
First Name:
Middle Name:
Last Name:
Nickname or Commonly Used Name:
Current Address: Street number and name
Building number
Apartment number
City
State
Zip code
Current Telephone:
Current E-mail:
Social Security Number:
Date of Birth:
Gender: Male
Female
Personal Contacts
Student Profile
8
List the primary (most important) contacts for the student and indicate their relationship to the student. Many primary contacts will be Make as many copies of this page as are needed to complete the personal contact information. Mark them Page 2 – a, 2 – b, etc. (Maximum of 15 contacts allowed in database.)
Name
Current Address: Street number and name
Building number
Apartment number
City
State
Zip code
Current Telephone:
Current E-mail
Place of Employment: (For immediate family members, if known)
Relationship of Legal Guardian to Student:
Mother Birth
Adoptive
Foster
Father Birth
Adoptive
Foster
Brother
Sister
Aunt
Uncle
Grandfather
Grandmother
Friend
Other (define):
Page 2 - ___ of ___ (total # of additional page 2‘s)
Student Profile
9
Legal
Student is his/her own legal guardian
Yes
No
Name of Legal Guardian:
Relationship of Legal Guardian to Student:
Mother
Father
Brother
Sister
Aunt
Uncle
Grandfather
Grandmother
Other (define):
Legal Guardian‘s Home Address:
Street # and Name:
Building #:
Apartment or Suite #:
City or town:
State:
Zip Code:
Home Telephone:
Work Telephone: Mobile Telephone:
Student has state or other ID card:
Yes Describe:
No
Student is registered to vote
Yes
No Eligible but not registered
Not of age
Home County
Home State:
Home County:
Home County Address:
Street # and Name:
Building #:
Apartment or Suite #:
City or town:
State:
Zip Code:
Home County Telephone:
Student Profile
10
Benefits
Social Security – SSI (Supplemental Security Income)
Yes Amount per month: $
No Never applied
Application pending Date:
Application denied Date:
Social Security – SSDI (Social Security Disability Income)
Yes Amount per month: $
No Never applied
Application pending Date:
Application denied Date:
Medicaid Yes Number:
No Never applied
Application pending Date:
Application denied Date:
Medicare Yes Number:
No Never applied
Application pending Date:
Application denied Date:
Private Insurance Yes Company:
Policy #:
Policyholder:
Type of Coverage:
None
Student Profile
11
Health And Medical Information
Medications
List all medications required by the student (including PRN). Update this section as frequently as needed using notifications from Health Services. Make as many copies of this page as are needed to complete the medication information. Mark them Page 5 – a, 5 – b, etc. (Maximum of 15 medications allowed in database.)
Medication:
Purpose:
Dose:
Schedule:
Potential Side Effects:
Student can self-medicate:
Yes
No
Assistance required:
Medication:
Purpose:
Dose:
Schedule:
Potential Side Effects:
Student can self-medicate:
Yes
No
Assistance required:
Medication:
Purpose:
Dose:
Schedule:
Potential Side Effects:
Student can self-medicate:
Yes
No
Assistance required:
Page 5 - ___ of ___ (total # of additional page 5‘s)
Student Profile
12
Environmental Restrictions
List all restrictions for the student (including temporary). Update this section as frequently as needed using notifications from Health Services or other sources.
Heat Yes Maximum time:
Maximum temperature:
Protective gear needed:
Date imposed:
Date lifted:
No
Cold Yes Maximum time:
Minimum temperature:
Protective gear needed:
Date imposed:
Date lifted:
No
Air quality Yes Maximum time:
Maximum air quality rating:
Protective gear needed:
Date imposed:
Date lifted:
No
Sunlight Yes Maximum time:
Protective gear needed:
Date imposed:
Date lifted:
No
Other: Yes Maximum time:
Protective gear needed:
Date imposed:
Date lifted:
No
Physical Activity Restrictions
Student Profile
13
List all restrictions for the student (including temporary). Update this section as frequently as needed using notifications from Health Services or other sources.
Bending Yes Maximum time:
Protective gear needed:
Date imposed:
Date lifted:
No
Lifting Yes Maximum weight:
Protective gear needed:
Date imposed:
Date lifted:
No
Standing Yes Maximum time:
Protective gear needed:
Date imposed:
Date lifted:
No
Kneeling Yes Maximum time:
Protective gear needed:
Date imposed:
Date lifted:
No
Sitting Yes Maximum time:
Protective gear needed:
Date imposed:
Date lifted:
No
Other: Yes Maximum time:
Protective gear needed:
Date imposed:
Date lifted:
No
Medical Conditions
Student Profile
14
List all conditions for the student (including temporary). Update this section as frequently as needed using notifications from Health Services or other sources. Make as many copies of this page as are needed to complete the medical condition information. Mark them Page 8 – a, 8 – b, etc. (Maximum of 6 conditions allowed in database.)
Include seizures, allergies and other conditions in this area.
Condition:
Type: Chronic
Temporary Start date:
End date:
Impact of condition:
Restrictions resulting from condition:
Complete any restrictions in the ―environmental‖ or ―physical activity‖ restrictions section.
Medications resulting from condition:
Complete any medications in the ―medications‖ section.
Condition:
Type: Chronic
Temporary Start date:
End date:
Impact of condition:
Restrictions resulting from condition:
Complete any restrictions in the ―environmental‖ or ―physical activity‖ restrictions section.
Medications resulting from condition:
Complete any medications in the ―medications‖ section.
Condition:
Type: Chronic
Temporary Start date:
End date:
Impact of condition:
Restrictions resulting from condition:
Complete any restrictions in the ―environmental‖ or ―physical activity‖ restrictions section.
Medications resulting from condition:
Complete any medications in the ―medications‖ section.
Page 8 - ___ of ___ (total # of additional page 8‘s)
Student Profile
15
Health Skills
Can take routine medications at work (e.g. knows when and how to use medication, understands and follows medication schedule, plans ahead for taking medication at work, etc.)
Yes
No
Can take PRN (as needed) medications at work (e.g. knows when and how to use medication, understands and follows medication schedule, plans ahead for taking medication at work, etc.)
Yes
No
Physical activity restrictions Bending
Lifting Max weight (lbs)
Standing
Kneeling
Sitting
Walking:
Other:
Accommodations Needed
Student Profile
16
Self-Care Information Eating Check all that apply except if “independent” is checked.
Independent (Do not check any other fields in this area.)
Requires partial physical assistance (e.g. set up
plate and utensils)
Describe:
Requires full physical assistance
Uses feeding tube
Requires adaptive eating equipment (e.g. adaptive
utensils)
Describe:
Requires special food preparation (e.g. pureed)
Describe:
Drinking Check all that apply except if “independent” is checked.
Independent (Do not check any other fields in this area.)
Requires partial physical assistance
Describe:
Requires full physical assistance
Requires adaptive drinking equipment
Describe:
Specific fluid requirements (e.g. no ice)
Describe:
Student Profile
17
Grooming and Hygiene (Check all that apply except if “independent” is checked.)
Independent in all grooming skills below (Do not check any other fields in this area.)
Showering or bathing
Independent (no assistance required)
Requires support
Describe:
Shampooing hair
Independent (no assistance required)
Requires support
Describe:
Applying deodorant
Independent (no assistance required)
Requires support
Describe:
Shaving Independent (no assistance required)
Requires support
Describe:
Hair styling Independent (no assistance required)
Requires support
Describe:
Applying make-up
Independent (no assistance required)
Requires support
Describe:
Showering or bathing
Independent (no assistance required)
Requires support
Describe:
Menstrual care
Independent (no assistance required)
Requires support
Describe:
Student Profile
18
Toileting Check all that apply except if “independent” is checked.
Independent (Do not check any other fields in this area.)
Requires partial physical assistance
Describe:
Requires full physical assistance
Uses Depends/Attends
Requires adaptive equipment (e.g. wheelchair accessible stall and sink)
Describe:
Dressing Check all that apply except if “independent” is checked.
Independent (Do not check any other fields in this area.)
Requires partial physical assistance
Describe:
Requires full physical assistance
Requires adaptive equipment or clothing (e.g. Velcro closures)
Describe:
Student Profile
19
Behavior Information Behaviors of Concern
Student has Behavior Management Plan
Yes
No
In development
Student has behaviors of concern (even if no BMP)
No
Yes (Complete list below.)
Antecedent(s) to behavior What happens before?
Behavior exhibited What is specific behavior?
Appropriate response What response is effective?
Consistent Environmental Restrictions (Due to Behaviors) Check all that apply.
Noise Describe specifics:
Gender of coworkers Males problematic
Females problematic
Space Describe specifics:
Illness Describe specifics:
Other: Describe specifics:
Other: Describe specifics:
Other: Describe specifics:
Student Profile
20
Funding And Service Information State Funding and Services
DDA (Developmental Disabilities Administration)
Yes Regional Office: Central
Eastern Shore
Western
Southern
Telephone #:
Address:
Services Requested:
Supported Employment
Day Habilitation
CSLA
Residential
Family/Individual Support Services
Date Case Opened:
No Never applied
Application pending Date:
Application denied Date:
DORS (Division of Rehabilitation Services)
Yes Counselor Name:
Office:
Telephone:
Case #:
Date Case Opened:
No Never applied
Application pending Date:
Application denied Date:
Resource Coordination
Yes Coordinator Name:
Office:
Telephone:
Case #:
Date Case Opened:
No Never applied
Application pending Date:
Application denied Date:
Student Profile
21
Federal Funding and Services
Medicaid Waiver Yes Services waivered:
Supported Employment
Day Habilitation
Residential
CSLA
No Never applied
Application pending Date:
Application denied Date:
MSB Services Information Key Dates
Date of admission to MSB:
Day:
Month:
Year:
Projected graduation date:
Month:
Year:
Program
Early Childhood Date of admission:
Date of transfer:
Reason for transfer:
EAP (Expanded Academics Program)
Date of admission:
Date of transfer:
Reason for transfer:
LIFE team Date of admission:
Date of transfer:
Reason for transfer:
SOLAR Date of admission:
Date of transfer:
Reason for transfer:
Student Profile
22
Residential Date of admission:
Date of transfer:
Reason for transfer:
MSB Address:
Telephone:
Primary Contact:
Primary Contact Telephone:
Services Check all that apply.
Occupational Therapy Primary Contact:
Physical Therapy Primary Contact:
Speech Therapy Primary Contact:
Orientation and Mobility Primary Contact:
Psychology Primary Contact:
Technology Primary Contact:
Social Work Primary Contact:
Disability Information
Primary Disability: Blindness
Visually Impaired
Secondary Disability: Mental retardation
Hard of hearing
Speech-Language
Emotional disturbance
Orthopedic impairment
Other health impairment
Specific learning disability
Multiple disabilities
Deaf-blindness
Traumatic brain injury
Autism
Counseling & Advisory (A) 8, 9, 10, 11, 12 (Circle One)
Moon, Hernandez & Neubert (2003) 23
Community Mobility Skills Profile
Name of Student:_______________________________ Date:___________________
General Mobility Yes No Not Observed Comments
1. Walks without difficulty
2. Climbs steps without difficulty
3. Uses elevators & escalators
without difficulty
If no, give details:
______________________________________________________________________________
______________________________________________________________________________
4. Uses a wheelchair
a. Uses manual wheelchair
b. Uses electric wheelchair
c. Uses manual on most surfaces
without help
d. Transfers to car without help
e. Transfers to car with help
f. Uses elevator without help
g. Uses elevator with help
If yes, describe level of independence:_________________________________________________
________________________________________________________________________________
Street Crossing/Pedestrian Skills Yes No Not Observed Comments
1. Safely crosses street independently
a. One lane
b. Two lanes
c. Three lanes
2. Safely crosses non-controlled
intersections
3. Safely crosses with light signal
a. Person/Hand
Counseling & Advisory (A) 8, 9, 10, 11, 12 (Circle One)
Moon, Hernandez & Neubert (2003) 24
b. Walk/Don’t Walk
Travel Skills Yes No Comments
1. Knows community safety
2. Uses exact change
3. Uses travel farecard independently
4. Tells time
5. Reads route sign in front of bus
6. Matches colors independently
7. Matches numbers independently
8. Recognizes outstanding building
and landmarks
9. Demonstrates appropriate social
bus riding skills (remains seated,
speaks in a normal voice, does not
interact inappropriately with bus
drivers or others)
10. Asks for assistance/uses phone in
emergency
11. Follows 1-2 step directions
12. Has an official state ID card
13. Has unofficial form of ID
14. Describe how the student communicates, indicating any assistive devices used or other means
of communication (i.e. ASL):_______________________________________________________
_______________________________________________________________________________
Bus/Rail
1. Individual lives within __________ blocks of a rail/bus/accessible van stop.
2. Bus/van route that stops closest to home ____________________________________
3. Can get to rail/bus/van stop by self
4. Can get a ride to bus/rail/van stop
Taxi/Paratransit Yes No
1. Can locate the phone numbers of three local cab companies and the
paratransit provider
2. Can dial the numbers of three local cab companies and ask for a cab to
specific location
Counseling & Advisory (A) 8, 9, 10, 11, 12 (Circle One)
Moon, Hernandez & Neubert (2003) 25
3. Can ask someone to call cab for ride to specific location
Bicycle Yes No
1. Can ride bicycle independently
2. Can ride bicycle correctly following safety procedures and traffic/laws (i.e.
rides with traffic, obeys lights)
Driving
1. Can develop the reading, reasoning and motor skills necessary to drive
2. Parents desire that student learns to drive
3. Understands accommodations and adaptations available for drivers with
disabilities
4. Is eligible for driver’s education course
5. Has financial resources to get training and apply for license
Counseling and Advisory (A) 8,9.10,11,12 (circle one)
(continues) 26
Name: _______________________________________ Date: ___________________
Sample Student Interview Form
DIRECTIONS: Interview the student and record responses.
ATTITUDE TOWARD DISABILITY
!. Tell me about your disability.
2. Are you in a special education program? Which one? Why?
3. How do you feel about this program? Is it helpful?
B. INTERESTS IN LEISURE ACTIVITIES
!. What do you do in your spare time? Sports? Hobbies? Church?
Extracurricular clubs at school?
2. What chores do you do at home?
3. Do you have friends? What do you and your friends do together?
4. On a perfect Saturday, what would you do?
C. FAMILY RELATIONSHIIIPS
1. What do you like best about your family?
2. Who usually helps you with schoolwork or other problems?
3. Is there anything that causes difficulties for you at home?
D. FUNCTIONAL SKILLS
1. If you had a job, how would you get to work?
2. Who selects your clothes?
3. Do you shop alone for your personal things?
4. Do you have an allowance of personal money from a job?
Counseling and Advisory (A) 8,9.10,11,12 (circle one)
(continues) 27
5. If you were home alone at dinner time, what would you eat and what would
you do to prepare this meal?
6. If you had $1000, what would you buy?
E. EDUCATIONAL INTERESTS
1. What classes would you like to take? Would you like to include vocational
classes?
2. Of all the classes you have taken, which one was the best? Why?
3. Do you want to go to school after high school?
4. What do your parents want you to do after high school?
F. WORK AND CLASS PREFERENCES
1. What teachers do you like best? Why? Least? Why?
2. Do you like to work alone or in a group?
3. When you work, do you like to sit most of the time or move around?
4. Do you prefer to work inside or outside?
5. Do you like to work on a computer?
6. Do you like to help people? Or work with things?
G. OCCUPATIONAL AND CAREER AWARENESS
1. Name as many jobs as you can. (time limit: 2 minutes)
2. Where do you begin to find a job?
3. What are some reasons people get fired?
4. What should you do if you are going to be absent or late to work?
Counseling and Advisory (A) 8,9.10,11,12 (circle one)
(continues) 28
H. FUTURE PLANS
1. What will you be doing during the next year, in 5 years, in 10 years toward the
following postschool outcomes?
Employment:
Education:
Living Arrangements:
2. Will you need help meeting your goals? Which one(s)?
3. Where would you get the help you need?
4. What concerns you most about the future?
Counseling & Advisory (A) 8, 9, 10, 11, 12 (Circle One)
(continues) 29
Vocational Critical Skills Checklist Student : Date of Report:
D.O.B.: Completed by: D.Quinn/
Grad. Year: Work Experience:
Comments (Strengths, Needs, etc.):
Goals and Objectives:
Motivators:
Interfering Behaviors:
Critical Skill Areas
Continuous prompting
throughout the sequence
(1)
(25%)
Less prompting
for acquisition/
still requires
continuous
monitoring
(2)
(50%)
Higher level skill acquisition with intermediate monitoring
(3)
(75%)
Supervision out of
visual field
(Independent)
(4)
(100%)
1. Work Performance
a) Work quality
b) Rate
c) Initiative
d) Stamina
e) Generalization Skills
2. Behavior
a) Appropriate self-control
b) Ability to accept changes in routine
c) Appropriate interactions with others
3. Interpersonal Skills
a) Response to constructive criticism
b) Leisure and break skills
4. Communication Skills
a) Ability to express wants and needs
b) Requests assistance when needed
c) Ability to talk about self appropriately
d) Expressive communication skills
1) Simple
2) Complex
e) Receptive communication skills
1) Simple
2) Complex
5. Self-Help-Skills
a) Personal hygiene skills
b) Manners
c) Appropriate dress
d) Bathroom use
6. Motor Skills
a) Gross motor skills
b) Fine motor skills
7. Travel Skills
a) On school grounds
b) Public Transportation
Counseling & Advisory (A) 8, 9, 10, 11, 12 (Circle One)
(continues) 30
Name:
Rules: 1. Finishing Task 3. Walk in school
2. Stay with group 4. Keep self to self
Date:__________
VOCATIONAL POINT SHEET
Time Activity Rules Followed
8:00 a.m.
Arrival/Hygiene/Breakfast 1 2 3 4
8:30 a.m.
Morning Meeting 1 2 3 4
9:00 a.m.
Recreation & Leisure 1 2 3 4
9:30 a.m.
Movement & Music 1 2 3 4
10:00 a.m.
Purchasing Group 1 2 3 4
10:30 a.m.
Recreation & Leisure 1 2 3 4
11:00 a.m.
Movie 1 2 3 4
11:30 a.m.
Music 1 2 3 4
12:00 p.m.
Lunch 1 2 3 4
Counseling & Advisory (A) 8, 9, 10, 11, 12 (Circle One)
(continues) 31
Name:
Rules: 1. Finishing Task 3. Walk in school
2. Stay with group 4. Keep self to self
Date:__________
VOCATIONAL POINT SHEET II
Time Activity Rules Followed
8:00 a.m.
1 2 3 4
8:30 a.m.
1 2 3 4
9:00 a.m.
1 2 3 4
9:30 a.m.
1 2 3 4
10:00 a.m.
1 2 3 4
10:30 a.m.
1 2 3 4
11:00 a.m.
1 2 3 4
11:30 a.m.
1 2 3 4
12:00 p.m.
Lunch 1 2 3 4
Counseling & Advisory (A) 8, 9, 10, 11, 12 (Circle One)
(continues) 32
Name: Date:
Work Card
= Goal Met =Goal Not Met Do NOT Draw
Line Thru
Use Straight if goal
not attempt-
2 points 0 points Faces ed or
required
Mon Tue
Wed Thurs Fri
General Behavior and Attitude:
3= GREAT--How you want them to behave all of the
time
2= GOOD --Did pretty well, but needs some
improvement
1= FAIR --Needs much improvement in behavior
and attitude
0= Poor --Unacceptable or inappropriate behavior
Total Daily Points:
Counseling & Advisory (A) 8, 9, 10, 11, 12 (Circle One)
(continues) 33
Name: Date:
= Goal Met =Goal Not Met Do NOT Draw
Line Thru
Use Straight if goal
not attempt-
2 points 0 points Faces ed or
required
Mon Tue
Wed Thurs Fri
General Behavior and Attitude:
3= GREAT--How you want them to behave all of the
time
2= GOOD --Did pretty well, but needs some
improvement
1= FAIR --Needs much improvement in behavior
and attitude
0= Poor --Unacceptable or inappropriate behavior
Total Daily Points:
Counseling & Advisory (A) 8, 9, 10, 11, 12 (Circle One)
Name: __________________________________________ Date: __________________
Career Portfolio Directions: Evaluate the student, using the rating scale on the right. Circle the appropriate number to
indicate the degree of competency. The rating for each of the tasks should reflect job readiness rather than
the grade given in the class.
EMPLOYABILITY SKILLS (Competencies that will enable the individual to obtain and retain a job; base
scores on what individual is able to do without any supports.)
SCALE
The student can: Never 25% 50% 75% Always
1. Establish realistic career goals/choices N 1 2 3 4
2. Display a positive attitude toward work (work ethic) N 1 2 3 4
3. Demonstrate a good record of attendance N 1 2 3 4
4. Display punctuality at school, work, and following breaks N 1 2 3 4
5. Display a pride in work N 1 2 3 4
6. Demonstrate honesty N 1 2 3 4
7. Demonstrate dependability N 1 2 3 4
8. Observe and follow classroom/work rules and regulations N 1 2 3 4
9. Display initiative (e.g., begin work without being asked,
assume additional responsibility, help others voluntarily) N 1 2 3 4
10. Work at a consistent pace N 1 2 3 4
11. Manage time appropriately N 1 2 3 4
12. Demonstrate work stability (remains on the job/task until completed) N 1 2 3 4
13. Work effectively under pressure or within time limits N 1 2 3 4
14. Keep work area clean N 1 2 3 4
15. Display respect for other people N 1 2 3 4
16. Show respect for property of others N 1 2 3 4
17. Seek help when needed N 1 2 3 4
18. React appropriately to constructive criticism N 1 2 3 4
19. Accept praise appropriately N 1 2 3 4
20. Assume responsibility for own actions/behaviors N 1 2 3 4
21. Demonstrate appropriate reactions to own mistakes
(e.g., acceptance, correction) N 1 2 3 4
22. Demonstrate appropriate problem-solving skills (e.g., identify
problem, list possible solutions, select a solution, evaluate results) N 1 2 3 4
23. Demonstrate willingness to learn new skills/information N 1 2 3 4
24. Demonstrate adaptability to charging situations N 1 2 3 4
25. Follow safety regulations N 1 2 3 4
26. Respond appropriately to classroom and/or job related emergencies N 1 2 3 4
27. Practice good hygiene/grooming N 1 2 3 4
28. Dress appropriately for work/specific job N 1 2 3 4
29. Correctly complete a job application N 1 2 3 4
30. Demonstrate appropriate job interviewing skills N 1 2 3 4
N 1 2 3 4
Counseling & Advisory (A) 8, 9, 10, 11, 12 (Circle One)
CAREER EXPLORATION ACTIVITY
Student Name: Date:
CAREER SPEAKER FORM
Speaker’s Name:
Speaker’s Job Title:
Student attended to the presentation
Student participated in the activity presented
Student asked questions
Student was able to maintain appropriate behavior during the presentation
Signature
Counseling & Advisory 8, 9, 10, 11, 12
(Circle One)
36
Future Planning Inventory__________________________
Parent/Guardian Form Please complete this future planning document and bring it to the upcoming Individual Education Planning conference scheduled for your son/daughter.
General Student Information
Student‘s name: ____________________________________________________________
first middle last
Social Security number: _______________________ Birthdate: _____________________ Anticipated graduation date: ____________________ Grade: ________________________
Current address: _____________________________ Phone number: _________________ Parent‘s name: _______________________________ Parent‘s business phone: _________ What kind of secondary curriculum do you feel best meets the needs of your son /daughter? ________ College preparatory ________ General education ________ Vocational I. Vocational/Postsecondary Education Options A. Upon graduation, what do you see your son/daughter doing for future education or training? (Please check all that apply) ________ Four-Year college/university ________ Private occupational training program ________ Community college ________ Military service ________ Technical college ________ Community education program What will your son/daughter be studying or training to be? __________________________________________________________________________ My son‘s/Daughter‘s level of motivation to succeed in the academic setting: ________ high ________ medium ________low The level of control my son/daughter believes he or she has over decision making and his/her individual success: ________high ________medium ________low My son‘s/daughter‘s ability to identify what he/she needs and how to get it: ________high ________medium ________low B. Upon graduation, in what kind of employment setting do you see your son/daughter engaged in? ________ Competitive employment: ________ Full-time ________ Part-time ________ Self-employment ________ Supported employment: ________ Full-time ________ Part-time ________ Sheltered employment: ________ Full-time ________ Part-time
Counseling & Advisory 8, 9, 10, 11, 12
(Circle One)
37
C. What type of job/occupation do you see your son/daughter working in one year after graduation? _______________________________________________________________________ D. What type of job/occupation do you see your son/daughter working in five years after graduation? _______________________________________________________________________ E. What work-related demands are being placed on your son or daughter at home, and what is his or her reaction to them? Activity Degree of Independence
(For example makes bed, carries out trash, mows lawn.)
Does Independently
Needs Guidance
Unwilling to Perform Task
1.
2.
3.
4.
5.
F. List any jobs or chores your son/daughter does now and enjoys. _______________________________________________________________________ _______________________________________________________________________ G. What jobs or work experience has your son/daughter had in your community? ____________________________ ________________________________ ____________________________ ________________________________ H. List any jobs your son/daughter seems to really dislike. ____________________________ ________________________________ ____________________________ ________________________________
II. Home Living Options A. Where do you think your son/daughter will likely live after graduation? (Please check one from this list.) __________ Large urban (100,000 population plus) What city? ________________ __________ Urban (30,000 to 100,000 population) What city? ________________ __________ Rural (under 30,000 population What town? _______________ __________ Farm B. (Please check one from this list.) __________Live independently in apartment or home Where? ___________________ __________ With family member Who? ____________________ __________ With support __________ Supervised apartment (which one?) _____________________ __________ Group home (which one?) ____________________________
Counseling & Advisory 8, 9, 10, 11, 12
(Circle One)
38
__________ College dormitory Where? _________________________ __________ Other, please describe __________________________________________ III. Recreational and Leisure Options A. Leisure Interest Inventory Check all of the following leisure activities in which your son or daughter currently spends free time. Athletic/Sports Activities ______ swimming ______ lifting weights ______ skiing ______ running ______ aerobics ______ canoeing ______ softball ______ basketball ______ riding motorcycle ______ walking ______ fishing ______ camping ______ riding bike ______ bowling ______ riding horses ______ other ______________________________________________ Large Group Events ______ movies ______ car races ______ ball games ______ horse, dog, car shows ______ music events ______ community education classes ______ other ___________________________________________________ Individual Activities ______ sewing ______ listening to music ______ Internet ______ handcrafts ______ cooking ______ shopping ______ reading ______ playing instrument ______ playing pool ______ caring for pets ______ writing letters ______ caring for lawn ______ talking on phone ______ watching TV ______ playing video ______ clean/repair car games ______ other ____________________________________________________________ Social Activities ______ dating ______ entertaining at home ______ attending church ______ picnicking ______ volunteering ______ belonging to a social club ______ eating out ______ driving around ______ spending time with family ______ dancing ______ other _________________________ or friends B. In which extracurricular activities would you like your son/daughter to participate during
high school? _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ Does your son/daughter need any specific supports or accommodations to participate in
this/these extracurricular activities? __________ Yes __________ No If yes, please describe: _____________________________________________ C. Future Leisure Activities Check any of the following leisure activity resources that are available in the community where you think your son/daughter will live following graduation: ______ YMCA OR YWCA ______ bowling leagues ______ recreation clubs, classes ______ city/county/state parks ______ movie ______ sports arenas ______ city recreation facilities ______ church groups ______ community ed center ______ other ___________________________________________________________
Counseling & Advisory 8, 9, 10, 11, 12
(Circle One)
39
Please list all the community leisure activities in which you hope your son/daughter will choose to participate after high school. __________________________________________________________________________
____________________________________________________________________________________________________________________________________________________ Does your son/daughter need any specific supports or accommodations to participate in these leisure activities? __________ Yes __________ No If yes, please describe: _______________________________________________________
IV. Transportation Options How will your son/daughter get around the community and to work? __________ drive own vehicle __________ drive family vehicle __________ use city bus transportation __________ take taxi __________ ride bicycle __________ walk __________ use special regional transportation system (i.e., bus between towns) __________ depend on others __________ other _________________
Does Now
Needs to Learn
Counseling & Advisory 8, 9, 10, 11, 12
(Circle One)
40
Are you willing to drive your son/daughter to work? __________ Yes __________ No How many miles? ___________________________________________________________
V. Financial Support A. Does your son/daughter need financial assistance in any of the following areas to reach his/her long-range goals? 1. Postsecondary education __________ Yes __________ No If yes, please check all of the following for which you would like information. __________ a. Division of Rehabilitation Services (DRS) __________ b. Pell Grants __________ c. Scholarships __________ d. Work study __________ e. Student loans __________ f. Supplemental Security Income (SSI) __________ g. Social Security Disability Insurance (SSDI) 2. Employment assistance __________ Yes __________ No If yes, please check all of the following for which you would like information. __________ a. Division of Rehabilitation Services (DRS) __________ b. Local Job Training Agency __________ c. State Job Service __________ d. Supplemental Security Income (SSI) __________ e. County social services __________ f. Rehabilitation centers 3. Home living assistance __________ Yes __________ No If yes, please check all of the following for which you would like information. __________ a. County Social Services __________ b. Supplemental Security Income (SSI)/medical assistance __________ c. Housing assistance—city government __________ d. Independent Living Center services B. Which of the following agencies have you contacted with regard to financial support for your son or daughter? __________ Not applicable __________ Division of Rehabilitation Services (DRS) __________ Local Job Training Agency __________ Social Security Office __________ County Social Services __________ Other, please describe __________________________________________ VI. Health-Related Needs A. When was the last physical examination completed for your son or daughter? (Date) ____________________ B. Does you son/daughter currently have any of the following needs? __________ medical (i.e., medications) __________ yes* __________ no __________ counseling __________ yes* __________ no __________ other ________________________________________________________ *Please explain __________________________________________________________ C. What are some supports your son/daughter may require in the future?
Counseling & Advisory 8, 9, 10, 11, 12
(Circle One)
41
_______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ VII. Currently, what is your greatest concern for your son/daughter‘s future? _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________
Counseling & Advisory 8, 9, 10, 11, 12
(Circle One)
42
How Did My IEP Meeting Go?
I worked hard to get ready for the IEP meeting by
learning to speak up for myself and being a good team member.
After the meeting is over, look at the following checklist to decide if the meeting went well.
Yes No
Were all the people I wanted at the meeting?
Was I introduced to everyone I did not know?
Did I get to ask questions?
Did other team members ask me what I thought?
Did I get to talk about the things I like to do and what I want for the
future?
Did the other team members listen to what I said?
Did I and my family, friends and advocates help decide on what was in
my IEP?
Does my program/IEP have goals for all the things I think are
important?
Do I like my IEP?
If you checked YES in most of the boxes on this page your IEP
should be just what you wanted.
If you checked a lot of NO’s, then you might need to talk to your
parents or school team member to let them know there are areas where
you have questions or that need some work.
Counseling & Advisory 8, 9, 10, 11, 12
(Circle One)
43
What goals will I be working on this year?
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
What 3 things did I like best about the meeting?
1.
2.
3.
What do I wish had been different about the meeting?
1.
2.
3.
Counseling & Advisory 8, 9, 10, 11, 12
(Circle One)
44
How Do I Know If My IEP is Working?
Circle Yes or No for each question
Am I making progress on learning what I need to know before
I finish school?
Yes No
Am I receiving the help I am supposed to receive Yes No
Have I had experiences that I have made me have new ideas
about what I want?
Yes No
Does my IEP need to change? Yes No
Will I have new goals? Yes No
Will I need new services? Yes No
Will I be able to get what I need when I graduate? Yes No
Am I learning what I need to know to become more
independent?
Yes No
Do I like the classes I am taking? Yes No
Am I learning new things? Yes No
Am I learning how to do things in the community? Yes No
Am I learning how to be friends with my classmates? Yes No
Am I learning how to be friends with my coworkers? Yes No
What has changed?
Are there changes I would like to make with my IEP? What are they?
Counseling & Advisory 8, 9, 10, 11, 12
(Circle One)
45
Counseling & Advisory (B) 8, 9, 10, 11, 12 (circle one)
46
IEP Invite to Student
Insert Date
Dear ________________________:
Your IEP planning meeting plays an important role in getting ready for your
future. And since it is YOUR future that is discussed during this meeting,
you are welcome and encouraged to attend. This is a time when your
teachers, therapists and parents all come together to talk about the progress
you have made this year and decide on the goals you will work on during the
next IEP cycle. Your opinion is VERY important!
Your IEP planning meeting will be ______________________ at
_____________. Please talk with Mom and Dad about being a part of this
important meeting. I hope you will be able to attend.
Sincerely,
Counseling & Advisory (B) 8, 9, 10, 11, 12 (circle one)
47
IEP/Transition Meeting Checklist
Student: ____________________________
Date of Meeting: _____________________
Anticipated Exit Date: _________________
Student Present YES NO
Resource Coordinator/Case Manager Present: YES NO
or representative from other services
Transition Timeline Discussed YES NO
DDA/DDS referral complete YES NO
Eligibility letter available?
DORS/RSA Referral complete YES NO
SSI referral complete YES NO
MA referral complete YES NO
Official Identification card YES NO
Discussion about Med Waiver Services
Provider Visits
Minimum 3 visits
Verification of provider visit
Choice letter
Service Funding Plan
MAPS-MD
Transportation/MetroAccess
Guardianship
Selective Service
Counseling & Advisory (B) 8, 9, 10, 11, 12 (circle one)
48
List of Rating Scales and Inventories
Counseling & Advisory B
1. Enderle-Severson Transition Rating Scale – Third Edition (ESTR-III)
ESTR Publications
www.estr.net
2. Reading-Free Vocational Interest Inventory – Second Edition (R-FVII:2)
Ralph L. Becker, Ph.D.
Counseling & Advisory C
1. Assess for Success – A Practitioner’s Handbook on Transition Assessment
Second Edition
A joint publication Corwin Press and DCDT
2. Functional Assessment Report (FAR)
Counseling & Advisory (B) 8, 9, 10, 11, 12 (circle one)
49
Personal Goals for Transition
Name:
Date:
Year I Plan to Graduate:
CAREER/VOCATIONAL
In my future, I want to .
This year, I have been learning
.
I want to learn how to .
DAILY LIVING
In my future, I want to .
This year, I have been learning
.
I want to learn how to .
COMMUNITY PARTICIPATION
In my future, I want to .
This year, I have been learning
.
I want to learn how to .
Counseling & Advisory (B) 8, 9, 10, 11, 12 (circle one)
50
RECREATION/LEISURE
In my future, I want to .
This year, I have been learning
.
I want to learn how to .
MONEY MANAGEMENT
In my future, I want to .
This year, I have been learning
.
I want to learn how to .
STRENGTHS
I am good at . This
is one of my strengths.
NEEDS
I need help with . This
is one of my areas of needs.
FAVORITE PART OF SCHOOL DAY
My favorite part of the day is
.
Counseling & Advisory (B) 8, 9, 10, 11, 12 (circle one)
51
Personal Information
My name is .
My date of birth is .
I live with
.
My address is
My phone number is
I like to
.
In school, I want to learn
.
(Signature)
Counseling & Advisory (B) 8, 9, 10, 11, 12 (circle one)
52
Planning for the Future
Personal Profile
Name of Student:______________________________________________
What does he/she like to do? With whom?
Where does he/se like to go? With whom?
What is her/his personality like?
Counseling & Advisory (B) 8, 9, 10, 11, 12 (circle one)
53
Relationship Map
Put your child’s name in the center. Put those people who are closest to him/her in the
near circle. These would be people who spend the most time with her/him. Include
family members, teachers, friends, neighbors, service providers, etc. In the next circle
put people who spend some time with him/her, but not as much as those in the first circle,
etc.
Name of student
Who spends the most time with your child? Family? Friends? Professionals? Do you want to change this?
Counseling & Advisory (B) 8, 9, 10, 11, 12 (circle one)
54
Envision the Future
Where does he/she want to be living? Will he/she need support? What kind?
Where does she/he want to be working? Will he/she need support? What kind?
How will he/she get to work and around the community? Will he/she need support?
What kind?
What does he/she want to do in his/her free time? Will he/she need support? What
kind?
______
Counseling & Advisory (B) 8, 9, 10, 11, 12 (circle one)
55
Who will his/her friends? Will he/she need support? What kind?
______
Are there post-secondary education/learning experiences that he/she wants? Will
he/she need support? What kind?
______
The goal that I will begin planning for is…
Be specific. How will you know when you have reached your goal? When do you
want to have achieved this goal? Will you realistically be able to achieve this goal?
______
______
Counseling & Advisory (B) 8, 9, 10, 11, 12 (circle one)
56
Obstacles
What stands in the way of me meeting my goal? Include such things as lack of:
information, services, time, money, etc.
______
Available Resources to Help Overcome the Obstacles
Physical Resources: What things (money, equipment, etc.) do I have that might be
helpful in working on this goal?
______
People Resources: What might some of these people do to help me work on this
goal? (refer to relationship map)
______
Community Resources: What community groups/organizations (church, civic
groups, clubs) might be helpful?
______
Social Service Resources: What social service agencies (school, vocational
rehabilitation agency, etc.) are available to help with this goal?
Counseling & Advisory (B) 8, 9, 10, 11, 12 (circle one)
57
What adult service providers are available to help with this goal?
What financial supports (SSI, Medicaid waiver, etc.) are available to help with this
goal?
______
Prioritize Your Options and Resources
Which resources look most promising?
Which ones will give you the most results with the least effort?
Which ones should you start with first?
1.
2.
3.
4.
5.
Develop Your Action Plan
What can you immediately begin to work on?
When will you have it done?
Who will help you?
Counseling & Advisory (B) 8, 9, 10, 11, 12 (circle one)
58
What is the desired outcome?
How will you know when you have accomplished it?
What will take more time?
USE THE ATTACHED ACTION PLAN FORM
ACTION PLAN FORM
In order to reach my goals…..
What needs to take place immediately --- within the next month
What needs to place down the roald? – within the next 3-6 months
Immediate Steps Who By When Outcome Evaluation
1.
2.
3.
4.
Down the Road Who By When Outcome Evaluation
1.
2.
3.
4.
Counseling & Advisory (B) 8, 9, 10, 11, 12 (circle one)
59
Preparing for My IEP Meeting
1. Introductions
My teachers are:
My program director is
My transition specialist is
My social worker is
My speech therapist is
My job coach is
2. Future Plans and Interests
I plan to graduate in _________________________.
When I graduate I would like to
.
Things I like to do for fun include:
3. IEP Goals – Things I am Learning in School
I am working at ________________________________. I work on
______________________________________________________.
Career Vocational goals help me learn about
.
Counseling & Advisory (B) 8, 9, 10, 11, 12 (circle one)
60
Daily Living goals help me learn about
.
Social Emotional goals help me learn about
.
Math goals help me learn about
.
Reading goals help me learn about
.
Speech and Language goals help me learn about
.
One of my strengths is
.
I want to learn more about
.
Counseling & Advisory (B) 8, 9, 10, 11, 12 (circle one)
61
Student Letter of Invitation to IEP Meeting
Insert Date
Dear :
My teachers have been helping me learn about my IEP goals and my
transition plan. I learned that my IEP goals are about things I will learn in
school. I also learned that I have a transition plan. It talks about things I can
do at home now that will help me be more independent when I am an adult.
My teachers tell me that there will be a meeting on ___________________
to talk about my progress at school and my new IEP and transition plan. I
especially would like to talk about ________________________________.
I would like you to come to my meeting to talk about my goals and my
future. I hope you will be there.
Sincerely,
_____________________________
Counseling & Advisory (B) 8, 9, 10, 11, 12 (circle one)
62
Counseling & Advisory (B) 8, 9, 10, 11, 12 (circle one)
Maryland School for the Blind Career Education Program
Student Preferences Update:10/8/05
To be completed by: CEP Staff Frequency & Timeframe: 2 times - At age 14-15 and age 19-20
Name: First, Middle and Last
Age: Check only one.
14-15 years old
19-20 years old
Date Completed:
Completed by:
1. What motivates the student to perform work or complete tasks?
(Check all that apply)
Praise
Money
Time with favorite person or people
Who?
Opportunity to do favorite activity What activity?
Food or drink
A sense of accomplishment
Using skills, talents or interests
Pleasing people
Being with people I like
Other:
Comments:
2. How does the student feel about each of these work conditions?
Counseling & Advisory (B) 8, 9, 10, 11, 12 (circle one)
63
(Check the word that fits best – always, sometimes or never.)
Work Conditions
RA
RE
LY
SO
ME
TIM
ES
US
UA
LL
Y
Working alone
Working in a small group (2-5 people)
Working in a large group (6 or more people)
Indoors
Work Conditions continued
RA
RE
LY
SO
ME
TIM
ES
US
UA
LL
Y
Outdoors
Noisy environment
Quiet environment
Busy environment
Work involving people
Work involving machinery (power tools, heavy machines, etc.)
Work involving equipment (e.g. copy machines, shredder, etc.)
Work that involves ideas or concepts
In casual clothing
In dressy clothing
In a uniform
Doing repetitive tasks
Doing varied tasks
In one place during the workday
Moving around during the workday
Unsupervised for most of the workday
Closely supervised for most of the workday
Using current skills
Using skills that require more training or education
Working with or around men
Working with or around women
3. How does the student feel about each of these work schedules?
(Check all that apply)
Counseling & Advisory (B) 8, 9, 10, 11, 12 (circle one)
64
Work Schedules R
AR
EL
Y
SO
ME
TIM
ES
US
UA
LL
Y
Working days (For example: 7:00 am – 3:00 pm, 8:00 am - 4:00 pm, 9:00 am to 5:00 pm)
Working evenings (For example: 3:00 pm – 11:00 pm, 4:00 pm – 12:00 midnight)
Work Schedules continued
RA
RE
LY
SO
ME
TIM
ES
US
UA
LL
Y
Working nights (For example: 12:00 midnight to 8:00 am)
Working weekends (Saturday and/or Sunday)
Working weekdays (Monday – Friday)
Working overtime (extra hours that originally scheduled)
4. What hobbies or activities does the student enjoy?
(Check all that apply)
Movies
Dance
Video or computer games
Other games (cards, board games, etc.)
Listening to music What kind(s)?
Playing music What instrument(s)?
Counseling & Advisory (B) 8, 9, 10, 11, 12 (circle one)
65
Watching sports What kind(s)?
Playing sports What kind(s)?
Arts and crafts What kind(s)?
Other:
Other:
Counseling & Advisory (B) 8, 9, 10, 11, 12 (circle one)
66
Student Skills and Abilities Update: 11/3/05
To be completed by: Teacher Frequency & Timeframe: 4 times - At ages 5 or 6, age 10, age 15 and age 20
Student
Date of Birth
Date Completed:
Completed By
Completed at age: (Check the age at which the form was completed.)
5 or 6 years old
10 years old
15 years old
20 years old
Sensory Skills And Abilities Refer to the Outreach Diagnostic Evaluation summary to complete this section if needed. Check all that apply (except if “Totally blind” is checked.)
Vision
Totally blind (Do not complete any more of the “vision” section. Go directly to Hearing
section.) Uses vision to complete most tasks Check only one.
Yes With magnification
Without magnification
No
Uses vision efficiently (makes judgments based on visual information quickly)
Yes
No
Requires time to make judgments based on visual information
Yes
No
Can discriminate colors Yes
No
With difficulty
Counseling & Advisory (B) 8, 9, 10, 11, 12 (circle one)
67
Specific factors that impact on functional use of vision: Check all that apply.
Contrast Yes
No
Lighting Low
Medium
High
Print/Symbol Size
Normal
Large
Color (check highly preferred combinations)
Black text on white background
White text on black background
Blue text on yellow background
Yellow text on blue background
Other:
Other factors:
Uses glasses Yes
No
Level of assistance needed to use vision accommodations (Refer to the combined Delphi/MSDE scoring system.) Check only one.
Full Physical Prompt
Partial Physical Prompt
Modeling Prompt
Verbal Prompt
Gesture Prompt
Independent
Describe specifics (e.g. help student retrieve from backpack and put on.)
Uses monocular Yes
No
Level of assistance needed to use vision accommodations (Refer to the combined Delphi/MSDE scoring system.) Check only one.
Full Physical Prompt
Partial Physical Prompt
Modeling Prompt
Verbal Prompt
Gesture Prompt
Independent
Describe specifics (e.g. help student retrieve from backpack and put on.)
Counseling & Advisory (B) 8, 9, 10, 11, 12 (circle one)
68
Uses magnifier Yes
No
Level of assistance needed to use vision accommodations (Refer to the combined Delphi/MSDE scoring system.) Check only one.
Full Physical Prompt
Partial Physical Prompt
Modeling Prompt
Verbal Prompt
Gesture Prompt
Independent
Describe specifics (e.g. help student retrieve from backpack and put on.)
Uses colored lenses
Yes
No
Level of assistance needed to use vision accommodations (Refer to the combined Delphi/MSDE scoring system.) Check only one.
Full Physical Prompt
Partial Physical Prompt
Modeling Prompt
Verbal Prompt
Gesture Prompt
Independent
Describe specifics (e.g. help student retrieve from backpack and put on.)
Hearing
Totally deaf (Do not complete any more of the “hearing” section. Go directly to Touch section.)
Can hear normal conversational voices
Yes
No
Uses hearing aid in one ear
Yes Left ear
Right ear
No
Level of assistance needed to use hearing aid (Refer to the combined Delphi/MSDE scoring system.) Check only one.
Full Physical Prompt
Partial Physical Prompt
Modeling Prompt
Verbal Prompt
Gesture Prompt
Independent
Describe specifics (e.g. help student retrieve from backpack and put on.)
Uses hearing aid in both ears
Yes
No
Counseling & Advisory (B) 8, 9, 10, 11, 12 (circle one)
69
Level of assistance needed to use hearing aids (Refer to the combined Delphi/MSDE scoring system.) Check only one.
Full Physical Prompt
Partial Physical Prompt
Modeling Prompt
Verbal Prompt
Gesture Prompt
Independent
Describe specifics (e.g. help student retrieve from backpack and put on.)
Sensitivity to sounds Check all that apply. Add others as needed.
Yes. Please list:
Fire alarm
Air conditioning
No
Touch
Can feel differences in textures Yes
No
Can feel differences in temperature Yes
No
Tolerates being touched Yes
No
Sensitivities to touch (e.g. tap on shoulder, hand on arm)
Yes Please list.
No
Taste and Smell
Has sensitivity to certain smells
List:
Has sensitivity to certain tastes
List:
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Communication Skills And Abilities Check all that apply in the following sections if the student uses multiple types of expressive language. (For example: Student uses a few signs, some vocalizations and words, and a communication device when it’s available.) Use Speech and Language Therapist or other evaluations or assessments to complete this section if needed. EXPRESSIVE LANGUAGE Non-Oral Expression
Uses facial expressions and/or body language. (e.g. natural gestures such as
pushing something as to indicate refusing or lifting up cup to indicate “drink”.) If checked, please describe below.
Describe facial expression and/or body language used
Explain what student is expressing
Uses sign language Check only one.
Basic Level
Intermediate Level
Advanced Level
Tactual
Oral Expression
Uses oral expression.
Oral communication primarily consists of: Check all that apply.
Vocalizations Please list below
Words Please list below
Phrases Please list below
Sentences
Conversation Describe vocalization, word or phrase Used Explain what student is expressing
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Augmentative Communication
Uses Voice Output Device Type/Brand Name:
With picture symbols
With textures
With object symbols
With parts of object symbols
With overlays
Uses low technology communication device
Choice Board
Communication Board
With picture symbols
With textures
With object symbols
With parts of object symbols
With overlays
RECEPTIVE LANGUAGE
Receptive language primarily consists of: Check all that apply.
Words
Phrases
Sentences
Conversation
Receptive language modalities used: Check all that apply.
Speech
Sign language
Objects
Picture symbols List consistent words, phrases, objects or
picture symbols understood by student What it conveys to student
Counseling & Advisory (B) 8, 9, 10, 11, 12 (circle one)
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Communication Strategies
Assist student to effectively communicate by: Check all that apply.
Allowing student time to process
Speaking slowly
Other:
Other:
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Cognitive Skills And Abilities Attention
Can usually attend to task independently
Maximum # of minutes:
Maximum # of hours:
Attending to task is variable List barriers to attending task
Requires assistance to attend to tasks (Refer to the combined Delphi/MSDE scoring system.) Check only one.
Full Physical Prompt
Partial Physical Prompt
Modeling Prompt
Verbal Prompt
Gesture Prompt
Judgment and Problem Solving
Problem solving abilities Check all that apply.
Can solve simple problems independently
Can solves complex problems independently
Sometimes needs assistance to solve problems
Always needs assistance to solve problems
Types of Problems Assistance needed
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Memory
Immediate recall (within one hour) Check only one.
Good
Fair
Poor
Short-term memory (within one week) Check only one.
Good
Fair
Poor
Long-term memory (after one week) Check only one.
Good
Fair
Poor
Sequencing
Able to follow 1 step independently Yes
No Note level of assistance needed
Level of assistance needed to follow 1 step (Refer to the combined Delphi/MSDE scoring system.) Check only one.
Full Physical Prompt
Partial Physical Prompt
Modeling Prompt
Verbal Prompt
Gesture Prompt
Able to follow 2 steps independently Yes
No Note level of assistance needed
Level of assistance needed to follow 2 steps (Refer to the combined Delphi/MSDE scoring system.) Check only one.
Full Physical Prompt
Partial Physical Prompt
Modeling Prompt
Verbal Prompt
Gesture Prompt
Able to follow 3 or more steps independently
Yes Maximum # of steps can follow:
No Note level of assistance needed
Level of assistance needed to follow 3 or more steps (Refer to the combined Delphi/MSDE scoring system.) Check only one.
Full Physical Prompt
Partial Physical Prompt
Modeling Prompt
Verbal Prompt
Gesture Prompt
Time Awareness
Can tell time Yes Check all that apply:
Analog clock
Digital clock
Talking clock
Braille clock
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No
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Understands lapse time Yes Check all that apply:
5 minutes
15 minutes
30 minutes
1 hour
More than 1 hour
No
Scheduling/Planning
Independently schedules and keeps appointments
Yes
No
Can problem-solve scheduling conflicts
Yes
No
Independently follows familiar routine Yes
No
Functional Reading Skills And Abilities
Non-reader. (Do not complete the rest of the reading section. Go directly to Writing section.)
Able to read: Check all that apply.
Print Print size needed:
Braille
Braille Use: Check only one.
Non-contracted
Contracted
Nemeth
Functional - reads select Braille
Reading Grade Level (approximate):
Check all the following functional reading skills the student possesses:
Survival words (e.g. words and signs commonly found in the environment such as “exit”,
“men”, “women”, “help”, etc.) Recognizes own name
Read and understand a work schedule
Read and understand a time sheet
Read and understand simple work instructions
Recognizes own name by symbol
Uses pictures or symbols
Other:
Primary learning media Check only one.
Braille
Auditory
Other:
Secondary learning media Check only one.
Braille
Auditory
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Other:
Functional Writing Skills And Abilities
Non-writer. (Do not complete the rest of the writing section. Go directly to Functional Math section.)
Uses Braille No
Yes Check all options student can use:
Mountbatton
Braille and Speak
Notetaker
Unibrailler
Slate and Stylus
Other:
Uses other writing accommodations:
No
Yes Check all that apply:
Felt marker
Dictation
Computer
Other:
Can produce own name
Yes Check all that apply.
Writes signature Independent
With assistance
Uses signature guide Independent
With assistance
Uses stamp Independent
With assistance
No
Writing is legible Yes
No
Functional Math Skills And Abilities
Can sort by: Check all that apply.
Texture
Configuration
Shape
Color
Size
Other:
Understands 1 to 1 correspondence Yes
No
Uses the math concepts and operations of: Check all that apply.
Addition
Subtraction
Multiplication
Division
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Can make purchases independently Yes
No
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Level of assistance needed to make purchases (Refer to the combined Delphi/MSDE scoring system.) Check only one.
Full Physical Prompt
Partial Physical Prompt
Modeling Prompt
Verbal Prompt
Gesture Prompt
Knows money has value Yes
No
Social Skills And Abilities
Select the response that best represents the student’s skills in each area.
RA
RE
LY
SO
ME
TIM
ES
US
UA
LL
Y
Conversation
Faces people when speaking
Initiates greeting people
Responds appropriately when greeted
Select the response that best represents the student’s skills in each area.
RA
RE
LY
SO
ME
TIM
ES
US
UA
LL
Y
Listens when others are talking
Stays on topic of conversation
Able to start a conversation when appropriate
Able to end a conversation when appropriate
Talks about appropriate subjects
Does not interrupt inappropriately
Shows interest in other people‘s conversation
Manners
Demonstrates social graces appropriate to the situation (Says “thank you”, “excuse me”, ”please”, etc.)
Understands impact of behavior on others (Speaking or laughing loudly, making faces, etc.)
Demonstrates attitudes appropriate to situation (Shows sorrow or sympathy, enthusiasm, respect, etc.)
Interactions
Interacts appropriately with peers
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Interacts appropriately with males
Interacts appropriately with females
Interacts appropriately with adults
Interacts appropriately with children
Interacts appropriately with authority figures (supervisor, law enforcement, teachers, etc.)
Work Etiquette
Understands chain of command
Understand implications of sexual harassment
Dresses appropriately for work setting and tasks
Grooming and hygiene is appropriate to work setting and tasks
Arrives to work on time
Leaves work at appropriate time
Knows appropriate behavior for break times
Understands conversation appropriate for supervisor
Understands conversation appropriate for co-workers
Physical Skills And Abilities Mobility
Walks with orthopedic canes Yes
No
Uses walker Yes
No
Uses wheelchair Yes Manual
Power
Scooter
No
Can walk short distances (within a home or office setting)
Yes
No
Can walk long distances (over 300 feet) Yes
No
Has functional pace indoors Yes
No
Has functional pace outdoors Yes
No
Can carry objects when mobile Yes
No
Typical gait Steady
Unsteady
Has functional balance in crowded situations
Yes
No
Has functional balance in un- crowded situations
Yes
No
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Endurance and Stamina
Can perform simple or un-demanding tasks for at least:
Maximum number of minutes:
Maximum number of hours:
Can perform complex or demanding tasks for at least:
Maximum number of minutes:
Maximum number of hours:
Can stand at least: Maximum number of minutes:
Maximum number of hours:
Can sit at least: Maximum number of minutes:
Maximum number of hours:
Reaching
Can reach objects that are at arm‘s length: Check all that apply.
Above waist level
At waist level
Below waist level
Cannot reach out for objects without assistance
Fine Motor, Dexterity and Range of Motion
Hand preference Right
Left
Left hand Check only one.
Full use
Limited use
No use
Right hand Check only one.
Full use
Limited use
No use
Left leg Check only one.
Full use
Limited use
No use
Right leg Check only one.
Full use
Limited use
No use
Head and neck Check only one.
Full range of motion
Limited range of motion
No range of motion
Palmer Yes
No
Pincer grasp Yes
No
Can transfer objects Yes Hand to hand
Container to container
Other:
Other:
No
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Travel Skills And Abilities
Type of traveler: Visual
White cane
Day only use
Night only use
Day & night use
Use in new environments only
Use for identification purposes only
Can travel INSIDE BUILDINGS on MSB campus:
Independently
With assistance
Describe assistance needed:
Can travel OUTSIDE on MSB campus:
Independently
With assistance
Describe assistance needed:
To learn new routes, student requires: Check only one.
Explanation without practice
Minimal instruction (less than 1 month)
Moderate instruction (1-3 months)
Extensive instruction (more than 3
months) Describe details if needed:
Travel supports student requires:
No supervision
Review of travel plan or area
Visual contact (e.g. can watch from within
approximately 5 feet)
Direct supervision (e.g. must watch
within approximately 1 foot)
Verbal prompting
Describe details if needed:
Can cross streets: Check all that apply.
In residential areas
With moving parallel traffic; semi-busy crossing
At lighted intersections
Uses bus: Independently
With assistance
Describe assistance needed:
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Uses taxi: Independently
With assistance
Describe assistance needed:
Uses subway/metro: Independently
With assistance
Describe assistance needed:
Orientation Skills And Abilities
Can orient self to indoor environments: Check only one.
With no assistance
With minimal assistance (1 month or
less) With moderate assistance (1-3
months) With extensive assistance (3 or more
months) Can acclimate to new table task work environment: Check only one.
With no assistance
With minimal assistance (1 month or
less) With moderate assistance (1-3
months) With extensive assistance (3 or more
months) Can acclimate to new room work environment: Check only one.
With no assistance
With minimal assistance (1 month or
less) With moderate assistance (1-3
months) With extensive assistance (3 or more
months) Can acclimate to new building environment: Check only one.
With no assistance
With minimal assistance (1 month or
less) With moderate assistance (1-3
months) With extensive assistance (3 or more
months) Can work left to right Yes
No
If no, why?
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Can work top to bottom Yes
No
If no, why?
Can move to next tasks or activities: Check only one.
With no assistance
With minimal assistance (1 month or
less)
With moderate assistance (1-3 months)
With extensive assistance (3 or more
months)
Knowledge of distances:
No understanding of distances
Knows approximately 3 feet (arms
length)
Knows approximately 10 feet or more
Describe details if needed:
Understands body size (height, weight) in relation to surroundings (e.g. understands if there is sufficient room to move between objects, past a person in a doorway, underneath a doorway, etc.)
Yes
No
Describe details if needed:
Office Equipment Skills And Abilities Check all that apply. Check only if student has sound basic knowledge of most common types of equipment listed that would assist them in immediately, or quickly, using an unfamiliar machine. Check all equipment student can use AND details regarding knowledge and experience with that equipment.
Computer List Details Below (e.g. Used for 1 year daily at job.)
Text to speech software (e.g. JAWS)
Other:
List Accommodations Used
Text to speech software (e.g. JAWS)
Other:
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Calculator List Details Below (e.g. Used for 1 year daily at job.)
List Accommodations Used Below
Abacus List Details Below (e.g. Used for 1 year daily at job.)
List Accommodations Used Below
Telephone List Details Below (e.g. Used for 1 year daily at job.)
List Accommodations Used Below
Large button phone
Other:
Calculator List Details Below (e.g. Used for 1 year daily at job.)
List Accommodations Used Below
Copy machine List Details Below (e.g. Used for 1 year daily at job.)
List Accommodations Used Below
Paper shredder List Details Below (e.g. Used for 1 year daily at job.)
List Accommodations Used Below
Postage machine List Details Below (e.g. Used for 1 year daily at job.)
List Accommodations Used Below
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Fax machine List Details Below (e.g. Used for 1 year daily at job.)
List Accommodations Used Below
Other: List Details Below (e.g. Used for 1 year daily at job.)
List Accommodations Used Below
Advocacy Skills And Abilities
Recognizes authority figures in workplace
Independently
With assistance
Describe:
Asks for help appropriately Independently
With assistance
Describe:
Identifies and states needs appropriately
Independently
With assistance
Describe:
Identifies and states wants appropriately
Independently
With assistance
Describe:
Knows personal strengths and weaknesses
Yes
No
If no, describe:
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Can verbalize basic personal information when needed (e.g. State name, telephone number, address, emergency contact)
Yes
No
Describe:
Can produce basic personal information when needed (e.g. Show paper with name, telephone number, address, emergency contact)
Yes
No
Describe:
Requests additional work or tasks Independently
With assistance
Describe:
Safety Skills And Abilities
Knows basic first aid Yes
No
Recognizes cautionary signs (e.g. “wet floor, “danger”, “out of order”)
Yes
No
Recognizes emergency situations (e.g. fire/smoke, injury/illness, danger)
Yes
No
Can respond to emergency situations Yes Check all that apply.
Can call 911
Can get appropriate person to help
Can call out for help
Can leave danger area
No
Can protect self (e.g. keep personal information to self, know who to go with, who to open door to, leave dangerous situation, etc.)
Yes
No
Can protect personal property (e.g. purse/wallet, purchases, keep money hidden, etc.)
Yes
No
Knows safety issues specific to job/work environment
Yes
No
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Combined Delphi/MSDE Scoring System Periodically in the Staff Skills and Abilities form, the level of assistance needed by a student needs to be documented. The following are the official Maryland School for the Blind categories and definitions for these levels of assistance. (The previous version included additional levels that are no longer in use (and have been incorporated into one of the following six levels. )
PROMPT LEVEL DEFINITION
Full Physical Prompt
Requires staff to place his/her hand over or under the student‘s hand and move it toward the response desired.
Partial Physical Prompt
Requires staff to touch the student to elicit desired response.
Modeling Prompt
Requires staff to imitate the desired response with the student imitating the staff‘s model.
Verbal Prompt
Requires staff to give a specific verbal direction in addition to the task direction. Given a task direction, the student is unable to perform correctly until another (more specific) verbal prompt is provided. A signed prompt is the equivalent of a verbal prompt for a student who is deaf/blind.
Gesture Prompt
Requires the staff to move is/her finger, hand or arm OR make a facial expression that communicates to the student specific information to elicit the desired response.
Independent
No staff intervention of any type is needed for the student to perform the task. The student is able to generalize task performance across all settings.
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SUMMARY OF SELF-AWARENESS INVENTORIES CAREER EDUCATION
The Maryland School for the Blind
STUDENT’S NAME:
Compiled by: Date Compiled:
SELF-ASSESSMENT INVENTORIES COMPLETED FROM: The Janus Job
Planner Series….
1. Interest Inventory
2. Working Conditions Inventory
3. Working Experience Inventory
4. Work Attitude Inventory
5. Self-Esteem, Confidence & Personality Inventory
6. Values Inventory
FINDINGS: All inventories are orally dictated and read to the student and the student’s
verbal responses are recorded by the evaluator. The following are the individual’s
inventory results.
1. Interest Inventory Results: The results are ranked according to the individual’s
priority preference.
Number 1 = highest preference and Number 8 = least preferred
RANKING WORK AREA/WORK PREFERENCE POINT SCORE
1 CLERICAL JOBS
2 SALES JOBS
3 SERVICE JOBS
4 PHYSICAL JOBS
5 DRIVING & OPERATING JOBS
6 MECHANICAL & REPAIRING JOBS
7 CARING & HELPING JOBS
8 CREATIVE JOBS
Evaluator:
Date Completed:
2. Work Conditions Inventory Results: The checked items indicate the student’s
preference.
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Evaluator: Date Completed:
_____ Work Indoors _____ Work Outdoors
_____ Work Alone _____ Work with Others
_____ Work with People _____ Work with Things
_____ Moving Around _____ Sitting Still
_____ Busy Place _____ Quiet Please
_____ Wear a Uniform _____ Wear Dressy Clothes
_____ Do the Same Task _____ Do Different Tasks
_____ Perform Unskilled Work _____ Perform Semi-Skilled Work
_____ Be Supervised _____ Not be Supervised
_____ Stay in Place _____ Travel Around
_____ Work with Ideas _____ Wear Casual Clothes
_____ Perform Skilled Work
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Things that are Important to Me Very
Important
Somewhat
Important
Not
Important
Personal Care
Getting dressed by myself 1 2 3
Taking care of my personal hygiene 1 2 3
Cutting my food when I eat 1 2 3
Making my own lunch or breakfast 1 2 3
Daily Living
Making my own bed 1 2 3
Learning to shop for groceries 1 2 3
Learning to cook 1 2 3
Helping my family with chores 1 2 3
Learning to use public transportation 1 2 3
Recreation/Leisure
Learning to get along with friends 1 2 3
Making new friends 1 2 3
Learning new games or hobbies 1 2 3
Visiting friends when I am not in school 1 2 3
Schoolwork
Reading 1 2 3
Math/using money 1 2 3
Computer 1 2 3
In-school job 1 2 3
Writing 1 2 3
Community Trips 1 2 3
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Other:
______
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Transition Interview Questions
Current Grade □ Repeat? □ Student‘s Name: Birthdate: Age: Date:
Interview conducted by:
Current address/telephone #: Counselor:
Student‘s Case Manager: School:
Interests
1
What are your hobbies or interests? What do you like to do in your free time?
2
What activities do you participate in?
3
What is your proudest accomplishment?
4
What do you like best about yourself?
5
Is there anything you would like to improve or change about yourself?
6
How do you get around now? What type of transportation do you use?
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School Based Information
7
What classes have you liked taking in school? Why?
8
What classes have you NOT liked taking in school? Why?
9 What classes would you like to take?
10 What do you do well?
11 What part of learning is hard for you? (Why do you have an I.E.P.?)
12
What will be your high school completer? 2 credits of a foreign language 2 credits of advanced technology 4 credits of a career/tech program
13
How do you learn best? Listening to directions Reading directions by yourself Watching someone demonstrate
14
Have you heard about the programs at the Thomas Edison High School of Technology? Are there any programs that interest you?
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Work Experience
15
Have you ever had a job where you have been paid?
16
Have you had a volunteer or unpaid work experience?
17
Have you started earning/earned SSL hours? If so, what have you done to earn them?
18
What jobs or careers have you thought about for yourself?
Future Plans
19
What do you plan on doing after high school? (employment, training, college, military)
20
Are you planning on going to college? Do you have any particular colleges in mind?
□ 2-year
□ 4-year
21
What do you consider important about the future?
22
Where do you see yourself living after you exit high school?
Student Signature
Date
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SURVEY OF INDOOR AND OUTDOOR RECREATIONAL ACTIVITIES
Student’s Name
Date
Person Completing the Form
Directions: Place a “ ” next to the activity that you would like to participate in.
Place an “o” next to the activities that you have already participated in.
Structured Indoor Activities (done by yourself)
_____ Computer games
_____ Video games
_____ Completing a puzzle
_____ Make a photo album
_____ Organizing something
_____ Listening to a talking book
_____ Reading a book/magazine/newspaper
_____ Completing a model airplane or similar project
_____ Arts and crafts
_____ Playing a specific song on a musical instrument
_____ Following a cooking recipe
_____ Sewing
_____ Take a class for fun
_____ Other
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Unstructured Indoor Activity (done by yourself)
_____ Solitary card games
_____ Painting/drawing/doodling
_____ Arts and crafts
_____ Listening to music
_____ Playing a musical instrument
_____ Watching a television show or movie
_____ Writing an email or letter
_____ Exercising indoors
_____ Polishing fingernails/putting on makeup
_____ Arranging flowers
_____ Go shopping alone
_____ Play games at an arcade
_____ Other
Unstructured Team/Group Outdoor Activities
_____ Fishing with a group
_____ Bird watching
_____ Group car drive
_____ Barbecuing/cooking outdoors
_____ Go on a picnic
_____ Attend a fair
_____ Go to the park with others
_____ Horseback riding
_____ Go to amusement park
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_____ Other
1. Tally up the number of indoor and outdoor activities checked that you
have an interest in trying:
Indoor_______________________
Outdoor_____________________
2. Were more indoor or outdoor activities checked off?
3. Were more activities done alone or group activities checked off?
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FAMLY INTERVIEW FORM
Student Name: Age/DOB:
Interviewer:
FAMLY INFORMATION
Name of Parent/Guardian:
Address:
Daytime Phone: Evening Phone:
Siblings Names:
Do siblings live with student? Other family members?
Applied for benefits? Y N Benefits Received:
Do you provide private services at home for your child? Y N
(confidential)
If yes, what services?
MEDICAL & EMERGENCY INFORMATION
Physician’s Name: Phone:
Insurance Information:
What medication(s) does your child take regularly?
Do these medications have any side effects that could affect their performance?
Does your child have any allergies? Y N If yes, please list them and treatment
needed:
Does your child have seizures? Y N If yes, how often?
Is there a protocol for recovery? (Describe):
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PREFERENCES FOR THE FUTURE
What would you most like your child to be doing after graduation?
Work:
Postsecondary:
Living Situation:
Social/Leisure:
Transportation:
Finances:
What do you think your child would most like to be doing after graduation?
Work:
Postsecondary:
Living Situation:
Social/Leisure:
Transportation:
Finances:
What is your vision for your child at age 30?
______
What do you see as your child’s greatest challenges? What are your fears for the
future?
What would like more information and/or training about?
Would you like information on how to apply for financial support for your child?
Y N
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COMMUNICATION
How does your child communicate best with others?
How does your child indicate a need?
How does your child express emotions?
How does your child indicate a preference or make a choice at home?
How does your child indicate a non-preference or “No”?
What kind of instructions can your child follow?
Does your child initiate communication? Y N How?
Does your child sustain communication? Y N
Does your child ask for help? Y N How?
Does your child use and understand manual signs? Y N Not applicable
Does your child use and understand PCS symbols? Y N Not applicable
Has your child ever used an assistive device to communicate? Y N If yes, name
of device/method?
Would you like to explore assistive/alternative communication methods? Y N
What devices/methods would you like information about?
BEHAVIOR SUPPORT
Does your child have challenging behaviors? (If yes, please describe):
When do these behaviors happen most?
Why do you think they happen?
Does your child have a Behavior Intervention Plan? Y N
Which intervention(s) were most effective?
Which intervention(s) was least effective?
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TRANSPORTATION
How does your child get to/from school?
How does your child get to activities/places after school and on weekends?
Does your child have a public transportation pass for individuals with disabilities?
Y N
Would you like your child to get one? Y N
Would you like information about public transportation for people with disabilities?
Y N
Who could transport your child to/from a jobsite in an emergency?
Student Action Yes- Alone Yes – with help No Priority?
Rides school bus
Rides public bus
Rides subway
Rides taxi
Rides paratransit system
Reads bus schedule
Reads subway map
Pays driver correct fare
Crosses street safely
HOUSEKEEPING
Does your family clean or do you use a cleaning service?
What cleaning products does your family use at home?
Bathroom: Kitchen:
Living Room: Dining Room: ______
Bedroom: Other:
Does your child receive an allowance? Y N Other Incentive:
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Student Action Yes-
alone
Yes-with
help
Assists
Others
No Like/Dislike Priority?
Kitchen
Dishes- machine sink
Sweeps floor
Mops floor
Wipes countertops & table
Wipes stovetop &
microwave
Takes out garbage
Bedroom
Makes bed
Straightens room
Vacuums
Does laundry
Bathroom
Scrubs toilet
Vacuums/sweeps floor
Mops floor
Cleans shower
Cleans mirror
Wipes countertop
Living Room & Dining Room
Dusts – large small
both
Vacuums
Polishes furniture
Outdoors
Rakes leaves
Mows lawn
Care for plants/lawn
Sweeps porch/balcony
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FOOD PREPARATION AND EATING (HOME)
What foods does your child prefer?
______
What foods does your child especially dislike?
Beverages likes/dislikes?
Dietary needs/restrictions/food allergies?
What table manners or eating behaviors are priorities?
Does your family eat together? Y N If yes, what meals?
What appliances do you use at home? ____Dishwasher ____Microwave
____Toaster____Toaster Oven ____Blender ____Gas Stove ____Electric Stove
____Coffee Maker____Other (list):
Student Action Yes-alone Yes-with help No Like/Dislike Priority?
Food Preparation
Indicates food
preference
Prepares snack
Prepares single meal
Assists making large
meal
Uses stovetop
Uses oven
Uses microwave
Sets table
Moves hot food
carefully
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Eating
Uses utensils
Uses napkin
Chews/swallows before
taking more food
Passes/receives food
Cleanup
Removes dishes/napkin
Places dishes in sink
Clears table of all
dishes
Washes/dries dishes –
puts in dishwasher
Stores leftovers
Puts dishes away
Empties dishwasher
COMMUNITY LIFE
Please list what establishments your family visits most, and student’s preferred
places:
Grocery store: Pharmacy:
Convenience store: Library:
Post office: Church/temple:
Bank: Hair Salon/Barber:
Video store: Park:
Shopping mall: Other:
Does your child take vacations? Y N Where?
Does your child carry a wallet/purse? Y N Does your child have an ID card?
Y N
Would you like your child to have an ID card? Y N
What clubs/organizations does your child participate/belong?
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Student Action Yes-
alone
Yes-with
help
Assists
Others
No Like/Dislike Priority?
Indicates preferred activity
Locates bathroom
Uses bathroom
Selects items to purchase
Asks for help if needed
Locates end of line
Waits in line
Budgets money for needed
items
Chooses items within
spending limit
Pays for items
Shops for groceries
Mails items
Emails/responds to emails
Shops for clothing
Selects/checks out books
and movies
Purchases movie
tickets/snacks
Locates stores in mall
Uses cell phone
Uses elevator/escalator
Uses appropriate behavior
in public
Locates information on the
Internet
Uses ATM/debit card
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SELF-MANAGEMENT
Student Action Yes-alone Yes-with help No Needs full
assistance
Priority?
Bathroom
Showers
Bathes
Brushes teeth
Uses mouthwash
Washes face
Cares for fingernails
Blows/wipes nose
Uses toilet
Brushes hair
Uses deodorant
Uses cologne/perfume
Applies makeup
Uses blow dryer
Bedroom
Chooses clothing
Dresses in pullover
shirt
Dresses n shirt with
adapted closure
Dresses in button-down
shirt
Dresses in pants with
button/zipper
Dresses in pants with
adapted closures
Places socks on feet
Places shoes on feet
Ties shoes
Uses adapted shoelaces
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Student Action Yes-alone Yes-with help No Needs full
assistance
Priority?
Dresses in bra
Dresses in underwear
Personal
Has had sexual
education
Understands
precautions to take
during intimate
relations
Takes care of menstrual
needs
SOCIAL AND RECREATION SKILLS
Does your child indicate preferences? Y N Does your child initiate
activities? Y N
Does your child sustain participation in activities? Y N For how long?
Activity Enjoys? Regular Location Priority?
Shopping
Going to movies
Watching DVDs
Playing board games
Watching TV
Playing cards
Going to sports events
Playing sports
Exercising in gym
Reading magazines
Using the Internet/email
Playing computer games
Playing video games
Listening to music
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Activity Enjoys? Regular Location Priority?
Going to park/being outdoors
Hanging out with friends
Going to amusement park
Reading a book
Going to concerts/plays
Talking on the phone
Texting friends
Other:
Who are your child’s friends?
Does your child visit friends/relatives?
Does your child date? Y N Does he/she want to date? Y N
Would you like your child to learn appropriate interactions and behavior for
dating? Y N
Student Action Yes- Alone Yes – with help No Priority?
Interaction different with family, friends,
strangers
Initiates interaction
Sustains interaction
Ends interaction
Age-appropriate interaction
Greets/says goodbye to others
HEALTH AND SAFETY
Student Action Yes- Alone Yes – with help No Priority?
Health
Tells others when sick or injured
Takes medication
Exercises regularly
Avoids illegal substances
Knows the effects of smoking
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Student Action Yes- Alone Yes – with help No Priority?
Eats nutritious foods
Understands birth control measures
Uses poisonous or harmful materials
carefully
Safety
Uses caution with strangers
Avoids and reports sexual abuse
Understands difference between
rape/assault and consensual sexual
relationship
Uses dangerous objects carefully
Exits building for a fire alarm/emergency
Recognizes purpose of smoke detector
Will call 911 in an emergency
Reports emergency situations to others
Uses caution with strangers
Uses home telephone
Uses cell phone
Cares for small cuts and wounds
Reads safety signs
MONEY MANAGEMENT
Student Action Yes- Alone Yes – with help No Priority?
Writes checks
Balances checkbook/account
Fills out deposit slip
Fills out withdrawal slip
Withdraws money at ATM machine
Deposits money at ATM machine
Uses debit card to make purchases
Uses credit card to make purchases
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Carries wallet or purse
Creates budget for expenses
Follows budget for expenses
Counts out dollars for purchases
Counts out dollars and coins for
purchases
Uses pre-counted money envelopes for
purchases
Pays bills
TIME AND SCHEDULES
Does your child wear a watch? Y N Analog or digital face watch?
Does your child use an alarm clock to wake up? Y N
Does your child use a calendar to plan events? Y N
Does your child know specific events/holidays? Y N
If you child does not wear a watch or use an alarm clock, does he/she use a cell
phone for timekeeping/waking up? Y N If not, how does your child keep a
schedule and how does he/she wake up in morning?
Student Action Yes- Alone Yes – with help No Priority?
Organizes activities with friends/family
Avoids scheduling two or more activities
for the same day/time
Schedules appointments
Remembers and keeps appointments
Prepares materials in advance for
activities
Arranges transportation for activities in
advance
Submits materials (homework, bill
payments, etc.) by specified date
Tells time with digital watch
Tells time with analog watch/clock
Associates events with specific time
Uses cell phone for clock
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MATH OPERATIONS
Student Action Yes- Alone Yes – with help No Priority?
Mentally adds/subtracts
_____1 digit numbers
_____2 digit numbers
_____3 digit numbers
Adds/subtracts by counting
Uses calculator to complete operations
Completes multiplication/division
problems
Completes algebraic equations
READING
Does your child read at home? Y N
If yes, what does your child read at home?
What topics does your child like to read about?
What topics does your child dislike reading about?
Does your child use a camera? Y N Video camera? Y N
Student Action Yes- Alone Yes – with help No Priority?
Reads books, newspaper/magazine articles
Looks at pictures in books, newspapers
and magazines
Sounds out new words
Pieces together familiar letter
combinations/words to decipher new
words
Recognizes specific site words
Understands what is read to him/her
Composes sentences in writing
Composes paragraphs/essays in writing
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Writes single word responses
Dictates self-composed sentences
Dictates self-composed paragraphs/essays
Dictates single word responses
Puts pictures or PCS symbols together to
tell a story
Creates composition with video camera
Identifies numbers 1-10
Identifies numbers 1-100
Can match numbers (ex. – if given a “6”
on a card, could identify “6” button on a
cell phone)
Adapted from Syracuse Community-Referenced Curriculum Guide, 1989; COACH,
1998; Snyder, 1991; RG
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Functional Life Plan-Staff Questionnaire Parents, please take a few moments to think about your student and answer these
questions.
Describe your student:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
What are YOUR dreams for your student? (list them no matter how big or small they
are):____________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
What are your fears for your student?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
What are your student’s strengths/interests?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
What are your student’s needs/dislikes?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
List at least three things you would like your student to work on during the upcoming
school year:
!.______________________________________________________________________
________________________________________________________________________
2.______________________________________________________________________
________________________________________________________________________
3.______________________________________________________________________
________________________________________________________________________
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Functional Life Plan Process
Schedule meeting
Each meeting will need a facilitator and a support person
2 weeks prior to meeting send home parent packet
2 weeks before meeting give packet to teachers
Hold meetings – parents and teacher should bring completed packets
Type notes of meeting
Distribute notes to all team members
Identify how conclusions from meeting will be used in goal development
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(Date)
Dear Parents/Caregivers:
We will be having a “Functional Life Plan” (FLP) for your son/daughter this school year.
In preparation for the meeting, we are asking you to complete the enclosed form. Please
include as much detail as you can. Keep in mind that at the FLP we will be planning for
you son’s/daughter’s future years at school, as well as, post graduation.
There is no “right” or “wrong” answers. Anything that you feel is important for people to
know, please include. Do not be afraid to “dream” about your son’s/daughter’s future,
even if you are not sure about the options after graduation. You will be asked to bring
your survey with you to the meeting.
Also enclosed is a brief description of some of the services post graduation. Please do
not allow the options to limit your thinking when completing the survey.
Within the next couple of weeks you will receive a notice of the scheduled date for your
son’s/daughter’s FLP meeting. Please make every attempt to attend. Also, please invite
family members, close friends, church members…any body that has a relationship with
your son/daughter. The more input we have, the better the plan will flow.
We are looking forward to working with you and your son/daughter in the FLP process.
Should you have any questions, please contact (teacher/transition specialist).
Thank you in advance for your cooperation.
Sincerely,
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Functional Life Plan
“Let not our needs determine our dreams…..
But let our dreams determine our needs”
Colleen F. Tomke
Keep the focus of your vision on your student’s strengths and interests. Think
about the things in life that you value and would like your student to have. Most
people value their relationships with others and being an active member of society.
We also tend to value being able to pursue things we are good at and using them for
something meaningful and purposeful.
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Top Ten Practical Tips For Parents
10. Keep a POSITIVE Attitude! Choose Happiness!
9. Invite people into your life – People want to help…they just don’t
know how!
8. Become knowledgeable! Educate yourself! Document everything
and keep copies together.
7. Always focus on your child’s STRENGTHS!
6. Give your child the chance to be “All he or she can be”
5. Dream big and continue to dream! Many people become
successful because of what “others believed they could do!”
4. Take one day at a time – realize the progress you’ve made!
3. Keep making friends! Somewhere along the way you will meet
someone who can help you in your daily work!
2. If you are not happy with the results you are getting, go up the
chain of command.
1. Sometimes we must create our own support system, with our own
family and close friends and also within the community.
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Functional Life Plan
Student: Age:
Graduation Date:
Attendees:
Functional Vision:
Functional Hearing:
Current Health Status:
“I am good at…/I like doing…”:
“When I graduate from ___________, I would like to live…”
“The most important supports that I need are…”
“During the day, I would like to…”
Self Care Skills:
Dressing
Hygiene
Bathroom
Eating
Snack Prep
Money Management:
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Time Management:
Mobility:
Communication:
Assistive Technology:
Hobbies/Recreation/Leisure:
Obtaining Employment:
Education/Training:
Personal Safety/Security:
Self-worth (things I do that make me feel good):
Behaviors:
Themes/Priorities:
Questions/Concerns:
To do list:
Maryland School for the Blind
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PROGRAM FOR TRANSITION
PARENT SURVEY
Student Name:__________________________________ Date of Birth:___________________________________ Proposed Date of Transition:_______________________ VOCATIONAL NEEDS
1. When he/she graduates from school, we would like our child to
participate in the following post-school programs:
______Competitive Full Time Employment ______Supported Employment ______Vocational/Sheltered Employment ______Other:
2 Please choose jobs that your child seems particularly interested in at this time. Mark those jobs with an X. If there are jobs that you feel your child would not work well in or that you would not like to see your child participate in please make those jobs with an O.
______Carpenter ______Food service ______Recycling ______Facilities Maintenance ______Delivery Service ______Laundry duties ______Health club assistant ______Groundskeeping ______Cleaning Service ______Trash Collection ______Landscaping ______Clerical ______Assembly ______Delivery Service
3. Are there any occupations in which you object to your child‘s participation?
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4. Are there any medical concerns relating to your child‘s vocational placement?
5. Circle all the skills that you need to be developed to help your child reach
his/her Vocational goals:
Self-Help
Work Quantity
Peer Relations
Work Habits and Attitude
Work Quality
Motivation
Relationship with Authority
Transition Skills
Initiative 6. What duties or responsibilities does your child have at home? 7. Following graduation from school, what do you hope that your child‘s living arrangements will be:
At home
Independent apartment (alone, with friends, with spouse?)
Group home
Other (Please specify)__________________________________________
8. What leisure and recreational activities does your child participate in with
family and friends?
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Maryland School for the Blind Career Education Program
Student Dream Sheet Last Update: 11/3/05
To be completed by: Student (See note and end of document if student is unable to complete.) Frequency & Timeframe: 2 times – At age 14-15 and again at age 19-20
Your Name:
Date Completed:
Your Age: 14-15 years old
19-20 years old
Completed By:
Relationship to Student:
Student
Family Member
Teacher or Para-educator
Other:
1. I would like to live in the following town or city and county when I graduate: (List more than one town/city or county if desired.)
Town or City: 1st choice: 2nd choice:
County: 1st choice: 2nd choice:
Comments:
2. I would like to live in the following type of housing after I graduate: (Check more than one if desired.)
Apartment
Condominium or Townhouse
House
Comments:
3. I‘d like to live with the following people after I graduate: (Check more than one option if desired.)
Alone
Friend(s)
Roommate(s) (People I don‘t know, or don‘t know well.)
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Parents
Other Family Member (Brother, sister, cousin, parent, etc.)
Boyfriend/Girlfriend
Husband/Wife
Other:
Comments:
4. I‘d like to continue my education after graduating from MSB:
Yes
No
Not sure
5. (If you checked ―yes‖ on question #4) I‘d like to continue my education
through: (Check all that apply.)
Continuing education courses at public school (Iocal)
WTC
Community College (2-year college)
Trade School
4-year College or University
GED
6. *My dream job would be…
Dream Job What I like about this job is: What interests me about this job is:
1.
2.
3.
7. The kind of employment situation I would like after graduation is:
Part-time (34 hours or less per week)
Full-time (35 hours or more per week)
Volunteer (no compensation for work)
Seasonal (work during part of the year, e.g. summer, spring, etc.)
Other:
8. After I graduate, the amount of money I need, or want, to earn is:
$ (Check only one of the following.) Per month year every two weeks (bi-weekly) week
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9. After graduation, the amount I‘d like to work each week is…
Number of days per week:
Number of hours per week:
Career Education Program Staff: The order of preference for who completes this form is 1)
The student 2) The student with help from a family member 3) A family member and 3)
An MSB staff person who knows the student well.
*Categorize each of the student‘s dream job responses (from question #6) into one of the following types - taken from the Interest Inventory:
Caring and Helping Jobs
Sales Jobs
Creative Jobs
Service Jobs
Mechanical and Repairing Jobs
Driving and Operating Jobs
Clerical Jobs
Physical Jobs
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Preferences and Interests
Name:
Date:
Understanding my preferences and my interests is important to help me
make plans for my future. They can help guide me in making my decisions
for work, where I want to live, and how I use my free time.
MY PREFERENCES AND INTERESTS JOB CHOICES
___________________________________ ___________________________
___________________________
___________________________
___________________________________ ___________________________
___________________________
___________________________
___________________________________ ___________________________
___________________________
___________________________
___________________________________ ___________________________
___________________________
___________________________
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Functional Life Plan-Parent Questionnaire
Parents, please take a few moments to think about your child and answer these questions.
Describe your child: _______________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
What are YOUR dreams for your child? (list them no matter how big or small they are):
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
What are you fears for your child? ___________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
What are you child’s strengths/Interests? ______________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
What are your child’s needs/dislikes? _________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
List at least three things you would like your child to work on during the upcoming
school year:
1. __________________________________________________________________
__________________________________________________________________
2. __________________________________________________________________
__________________________________________________________________
3. __________________________________________________________________
__________________________________________________________________
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Transition Services-Parent/Guardian Questionnaire
Employment After graduation from school, I would like to see my son/daughter working:
_____ Full time or part time in the community without any support working
in the area of ____________________________________________
_____ Full time or part time in the community with support from a job coach
working in the area of _____________________________________
_____Working in a sheltered or center-based program
_____ I do not expect my son/daughter to work
_____ I am not sure at this time
Paid employment is an important consideration for long-term employment goals
_____YES _____NO
Have there been opportunities for part time employment (paid or volunteer)? _______
Additional Comments: _____________________________________________________
________________________________________________________________________
________________________________________________________________________
Education After graduation from school, my education goals for my son/daughter are:
_____ Attend a college program with emphasis on life skills curriculum
_____ Vocational training to specific to long-term employment goals
_____ Participation in adult education classes
_____ I am not sure at this time
_____ I am not planning for my son/daughter to participate in further education
Additional Comments: _____________________________________________________
________________________________________________________________________
________________________________________________________________________
Adult living Where do you envision your son/daughter living as an adult?
________________________________________________________________________
________________________________________________________________________
Does you son/daughter currently have regular chores or household responsibilities?
________________________________________________________________________
________________________________________________________________________
Does you son/daughter assist with meal planning and preparation? __________________
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How much supervision does you son/daughter need?
_____ Continual, 24 hour supervision
_____ Close supervision-can be alone in another room with an adult in the house
_____ Can be home alone for brief periods of time
_____ Can be home alone for extended periods of time, with an adult home
overnight
_____ Can be left alone overnight
What do you feel is the most important area to address in order to achieve greater levels
of independence as an adult? ________________________________________________
________________________________________________________________________
________________________________________________________________________
Additional Comments: _____________________________________________________
________________________________________________________________________
________________________________________________________________________
Independent Living What areas of self-help/personal hygiene are of most concern to you at this time?
________________________________________________________________________
________________________________________________________________________
Does your son/daughter receive an allowance? _________
Does he/she use a wallet? _________
Are there opportunities for making purchases in the community? ___________________
________________________________________________________________________
Does he/she use a bank account? __________
Do you feel you son/daughter is able to speak up for himself/herself or make needs
known? __________
Additional Comments: _____________________________________________________
________________________________________________________________________
________________________________________________________________________
Community Participation and Recreation/Leisure Does you son/daughter have special friends? __________
Does he/she need assistance to make leisure plans? __________
Does he/she use the telephone independently? __________
What does he/she do for fun? ________________________________________________
________________________________________________________________________
Are there community recreational opportunities with peers? _____ How often? _____
How do you anticipate he/she will travel within the community as an adult?
_____Walk _____Metro _____Bus _____Car/Cab
Do you think he/she will obtain a driver’s license? __________
Additional Comments: _____________________________________________________
________________________________________________________________________
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Future planning Does you son/daughter have an understanding of his/her disability and how it impacts
their day-to-day abilities?
After graduation, what do you believe will be your son/daughter’s primary means of
income or financial support?
_____SSI/Social Security
_____Own wages
_____Your support
_____Not sure at this time
Have you submitted applications to DDA (Maryland residents), DDS (DC residents),
CSB (Virginia residents) for adult support services __________
Does your son/daughter receive SSI? __________
Does your son/daughter receive Medical Assistance? __________
Have you considered issues related to guardianship when your son/daughter turns
18? __________
Have you obtained legal guardianship (for students 18 years and older)?
Do you need any additional information regarding the above mentioned services?
________________________________________________________________________
________________________________________________________________________
Additional Comments: _____________________________________________________
________________________________________________________________________
________________________________________________________________________
Student Name: _______________________________________________________
Parent Signature: _____________________________________________________
Date: _______________________________________________________________
Thank you for providing your opinions and ideas. The valuable information you have
shared will be useful as we work together as a team to assist your son/daughter to
achieve future goals and dreams.
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COURSE OF STUDY PLAN Date of Plan:_____________________________ Student Name:______________________________________________ DOB:________________________________________ COURSE OF STUDY Activities of daily living Job Sampling & Employment Training Supported employment
Potential employment
Employment training
Education
Independent Living PROJECTED EXIT DATE: ___________________________
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FUNCTIONAL CAREER DEVELOPMENT PORTFOLIO
Student Name:___________________________________ DOB:__________________________ My Functional Career Development Portfolio was officially begun on this date: Date:__________________________ Grade:________________________ Student Signature:____________________________________________________ Staff Signature:_______________________________________________________
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PROGRAM FOR TRANSITION-PARENT SURVEY
Student Name:__________________________________ Date of Birth:___________________________________ Proposed Date of Transition:_______________________ VOCATIONAL NEEDS
2. When he/she graduates from school, we would like our child to
participate in the following post-school programs:
______Competitive Full Time Employment ______Supported Employment ______Vocational/Sheltered Employment ______Other:
3 Please choose jobs that your child seems particularly interested in at this time. Mark those jobs with an X. If there are jobs that you feel your child would not work well in or that you would not like to see your child participate in please make those jobs with an O.
______Carpenter ______Food service ______Recycling ______Facilities Maintenance ______Delivery Service ______Laundry duties ______Health club assistant ______Groundskeeping ______Cleaning Service ______Trash Collection ______Landscaping ______Clerical ______Assembly ______Delivery Service
9. Are there any occupations in which you object to your child‘s participation?
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10. Are there any medical concerns relating to your child‘s vocational placement?
11. Circle all the skills that you need to be developed to help your child reach
his/her Vocational goals:
Self-Help
Work Quantity
Peer Relations
Work Habits and Attitude
Work Quality
Motivation
Relationship with Authority
Transition Skills
Initiative 12. What duties or responsibilities does your child have at home? 13. Following graduation from school, what do you hope that your child‘s
living arrangements will be:
At home
Independent apartment (alone, with friends, with spouse?)
Group home
Other (Please specify)__________________________________________
14. What leisure and recreational activities does your child participate in with
family and friends?
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Career Cluster Collage
Group Project
Purpose: Students should be in groups of 3-4 students. Each group will be
responsible for creating a collage and presentation for one Career Cluster.
Supplies: 1 Piece of Poster Board for each student, various magazines to cut
pictures out of, newspapers, scissors, glue sticks, markers.
Project Directions
Speaker –
Assist group members in developing research for the speech and help
cut and paste the collage
Prepare the speech on Career Cluster Collage
Give the speech to the class
Researcher(s) –
Use the Career Cluster booklet to gather information for the speaker
Research topics should include
Introduction of the Career Clusters
Characteristics of workers in this career path
Examples of jobs found in this Career Cluster
Elective courses recommended for this career path
Activities to be involved in
Want ads from the local newspaper that fit the Career Cluster
Collage Workers –
Cut letters or use letter guide and pens for the title of your Career
Cluster
Cut out pictures that represent jobs found in your Career Cluster
Glue/paste pictures onto paper
Label pictures with the “job title”
Tape collage on board on day of presentation
****Note: All group members must be in front of the class during the presentation.
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CAREER CLUSTER DESCRIPTIONS
ARTS, MEDIA & COMMUNICATION SUBTITLE: FUNCTIONAL COMMUNICATION SKILLS Students interested in this cluster are preparing for functional life skill activities that include all methods of communication available to increase the quality of daily living, independent living, vocational, and peer interaction. BUSINESS MANAGEMENT & FINANCE SUBTITLE: PURCHASING SKILLS Students interested in this cluster are preparing for basic money handling including accurate counting and purchasing of required items in order to function in daily living. CONSTRUCTION & DEVELOPMENT SUBTITLE: FACILITIES MANAGEMENT SKILLS Students interested in this cluster are preparing to work on site with facilities to ensure that cleanliness and order are available for the working public. CONSUMER SERVICE, HOSPITALITY & TOURISM SUBTITLE: RETAIL SKILLS Students interested in this cluster are preparing for activities in customer service situations, such as food preparation, food handling, food delivery, doorperson activities, and telephone answering skills. ENVIRONMENTAL, AGRICULTURAL & NATURAL RESOURCES SUBTITLE: LANDSCAPING SKILLS Students interested in this cluster are preparing for outdoor work experiences such as landscaping, mulching, conservatory work, and horticultural experience.
Counseling & Advisory (B) 8, 9, 10, 11, 12 (circle one)
137
HEALTH & BIOSCIENCES SUBTITLE: PERSONAL MANAGEMENT and SELF-AWARENESS SKILLS Students interested in this cluster are preparing for all activities of daily living through mastery of personal management including but not limited to proper toileting, proper hand washing, appropriate social interaction with peers and adults. HUMAN RESOURCE SERVICES SUBTITLE: RECREATION AND LEISURE SKILLS Students interested in this cluster are preparing to function with some independence and choice in their ability to access community based recreation and leisure activities. INFORMATION TECHNOLOGY SUBTITLE: COMPUTER & ASSISTIVE TECHNOLOGY SKILLS Students interested in this cluster are preparing to access the internet for business or social interaction and assistive technology aids for better performance in daily living activities. MANUFACTURING, ENGINEERING & TECHNOLOGY SUBTITLE: VOCATIONAL WORKSHOP SKILLS Students interested in this cluster are preparing to work in activities offered in a vocational center including clerical work, labeling, packing boxes, sorting, and assembly skills. TRANSPORTATION TECHNOLOGIES SUBTITLE: SAFETY IN THE COMMUNITY SKILLS Students interested in this cluster work on learning basic independence
in the community including safety in public situations, street crossing,
awareness of danger, food safety, and a general understanding of
household safety measure
Counseling & Advisory (B) 8, 9, 10, 11, 12 (circle one)
138
TRANSITION CAREER CLUSTERS (pg 1)
STUDENT NAME: GRADE:
Career Cluster Exposure/Date Achieving Initials
Arts, Media &
Communication
Business Management
& Finance
Construction &
Development
Consumer Service,
Hospitality &
Tourism
Environmental,
Agricultural &
Natural Resources
Counseling & Advisory (B) 8, 9, 10, 11, 12 (circle one)
139
TRANSITION CAREER CLUSTERS (pg 2)
STUDENT NAME: GRADE:
Career Cluster Exposure/Date Achieving Initials
Health & Biosciences
Human Resource
Services
Information
Technology
Manufacturing,
Engineering &
Technology
Transportation
Technologies
Counseling & Advisory (B) 8, 9, 10, 11, 12 (circle one)
140
REVIEW OF SKILLS CHECKLISTS
Student:____________________________________________________
Date:________________________
Reviewed by:_______________________________________________
Readiness
Basic Work Skills
Matching and Sorting
Pre-reading
Number & Quantity Concepts
Group Skills
Social Skills
Vocational Skills
Use this form as necessary when any of the checklists have been previously
completed. Please initial and date the original form found in the previous graded
section of the portfolio, copy, and file in this section. Return the original to its
proper place.
If the student has not had any of the skills checklists completed previously record
the information in the longer forms in the binder.
Counseling & Advisory (C) 8, 9, 10 (Circle One)
141
INITIAL TRANSITION PLANNING Ages 14-16 Student Name: Date of Birth: Age:
Course of Study Coordinated set of transition activities
Linkages Parent Survey Post-school Outcome
Academic
Activities of Daily Living
Employment Training
Social Interaction Skills
Behavioral
Counseling & Advisory (C) 8, 9, 10 (Circle One)
142
Fine Motor/ Eye Hand Integration date (8th
) date (9th) date (10
th) date (11
th) date (12
th)
1. Pick up and explore objects
- using 1 hand
- using 2 hands in coordination
- using hands and eyes together
2. Put items purposefully in specific location
- place on surface without dropping
- put into open container
- put into snug container
3. Pull items apart
- requiring only 1 hand
- using 2 hands
4. Put items together
- requiring only pushing w/1 hand
- using 2 hands
5. Stabilize materials being worked on
- hold down to table or other surface
- hold relative to other hand/material being used
- manipulate relative to other hand/material being used
6. Pick up small objects
- using hand grasp
- using finger grasp
- using pincer grasp
7. Complete inset puzzles
- up to 6 pieces
- 6+ pieces
Counseling & Advisory (C) 8, 9, 10 (Circle One)
143
Imitation
date (8th
) date (9th) date (10
th) date (11
th) date (12
th)
1. Respond to imitation of own actions
- pause? look? repeat?
2. Imitate rhythmic motor movements paired with sounds
- 1:1 play with adults
- small group setting with peers
- peek-a-boo, pat-a-cake, row the boat, etc.
- circle-time songs
3. Imitate 1-step motor actions using interesting objects
- 1:1 play with adults
- small group setting with peers
- car, hammer, playdoh, crayon, doll, etc.
4. Imitate 1-step actions using body
- 1:1 with adults
- small group setting with peers
- clap, stomp, jump, wave, touch, etc.
5. Imitate fine motor movements
- 1:1 with adults
- small group setting with peers
- manipulating materials
6. Imitate fine and oral-motor movements of body
- 1:1 with adults
- small group setting with peers
7. Respond to adult‘s imitation of own sounds/words
- pause? look? repeat?
Counseling & Advisory (C) 8, 9, 10 (Circle One)
144
date date date date date 8. Imitate sounds/words with rhythmic action
- repeated sound/word to accompany large body movements
- repeated sound/word to accompany use of objects
9. Imitate words or word approximations on request
- within context of meaningful activity
10. Imitate phrases and/or simple sentences
- within context of structured, meaningful activity
11. Imitate peer language
- within context of structured, meaningful activity
- within context of everyday peer interactions
12. Generalize use of imitated language
- learned in one setting and used in similar but new setting
- borrowed language from TV or videos
- routine phrases
Counseling & Advisory (C) 8, 9, 10 (Circle One)
145
Group Skills
date (8th
) date (9th) date (10
th) date (11
th) date (12
th)
1. Observe group activity from a distance
- note specific activity
2. Approach structured group activity for short periods of time
- note specific activity
3. Stay with group during short activity (1 to 5 minutes)
- given individual materials to manipulate
- note visual structure used to define area
4. Stay with group during activity to completion (up to 10 minutes)
- given visuals/manipulative component to activities
- note visual structure used to define area/activities
5. Participate in circle-time songs/games by listening and watching
- note specific activity/adaptations
6. Participate in circle-time songs/games by imitation
- note specific activity/adaptations
7. Participate verbally in circle-time songs/games
- note specific activity/adaptations
8. Participate in circle-time by looking at/listening to book
- note specific book/adaptations
9. Participate in circle-time by making choices of activities
- note visual choice system used
10. Participate in teacher-led group games by waiting/taking turns
- note visuals used
Counseling & Advisory (C) 8, 9, 10 (Circle One)
146
date date date date date 11. Participate in group games involving motor imitation (Simon Says, Follow the Leader, etc.)
- note specific games and adaptations
12. Participate in group games by passing out to/collecting materials from peers
- note specific games/materials/adaptations
13. Participate in group games involving taking turns with peers
- note specific games/adaptations
14. Generalize group skills to larger group settings with less physical structure
- note specific activities/settings
Counseling & Advisory (C) 8, 9, 10 (Circle One)
147
Social
date (8th
) date (9th) date (10
th) date (11
th) date (12
th)
1. Play comfortably in proximity to adults
- note who and where
2. Approach adults for comfort when hurt or distressed
- note who and why
3. Look briefly to adults to monitor behavior
- note who
- note why
Share attention
Permission
Clarification/information
Assistance
4. Play in proximity to peers
- tolerate noise and movement without avoiding/becoming upset
- in teacher-led, structured settings
- in free play settings in classroom centers
- note length of time
5. Parallel play alongside peers
- without taking others toys or hoarding materials
- in teacher-led, structured settings
- in free play settings in classroom centers
- note length of time
6. Observe/watch others
- note who and in what activities
- in teacher-led, structured settings involving interesting materials
- in free play settings in classroom centers
Counseling & Advisory (C) 8, 9, 10 (Circle One)
148
date date date date date 7. Respond to/cooperate with others (1-step)
- give out/share materials with adult mediation
- respond to peer initiation with adult mediation
- notice when others imitate his/her actions
8. Imitate others in teacher-led, structured activities
- imitate use of objects
toys, musical instruments, art materials, etc.
- imitate body movements
parts of songs or routines
on cue or to achieve a goal
- vocal/verbal imitation
part of song or routine
on cue or to achieve a goal
9. Imitate others in free play settings in classroom centers
- imitate use of objects
toys, musical instruments, art materials, etc.
- imitate body movements
parts of songs or routines
on cue or to achieve a goal
- vocal/verbal imitation
part of song or routine
on cue or to achieve a goal
10. Initiate contact with others to continue an interrupted enjoyable activity
- note who and what activities
11. Initiate contact for spontaneous play with others
- note who and what activities
Counseling & Advisory (C) 8, 9, 10 (Circle One)
149
date date date date date 12. Take turns with an adult in structured settings
- note visual cues used for turn-taking
- wait for turn/watch others‘ turn
- anticipate/offer turn
13. Take turns with peer(s) in teacher-led, structured settings
- note visual cues used for turn-taking
- wait for turn/watch others‘ turn
- anticipate/offer turn
14. Take turns with peer(s) in free play in classroom centers
- note who and what activities
15. Follow simple rules in teacher-led, structured games
- table-based games (at 1:1 teaching, in centers)
- motor games (at circle, outside)
16. Follow rules in peer play
- knows rules are for everyone/sense of ―fairness‖
- table-based games
- motor games
Counseling & Advisory (C) 8, 9, 10 (Circle One)
150
Cognitive/Readiness Skills date (8th
) date (9th) date (10
th) date (11
th) date (12
th)
Basic Work Skills
1. Attend to materials
- searches out hidden items
- explores cause and effect
- tracks movements
2. Work to completion of activity(-ies):
- all materials either ‗disappear‘ or are affixed to a surface
- all materials are used
- all instructions are completed
3. Anticipate work routine/follows work system (note details on work system
worksheet)
- indicates ‗finished‘ by placing items in designated place (in a container, on a shelf, etc.)
- at work settings
- in other settings (play centers, snack, group, etc.)
- completes activity(-ies) independently
- at work settings
- in other settings (play centers, snack, group, etc.)
4. Inhibit motor responses to increase scanning
- field of 2 items
- field of 3-5 items
- field of 6+ items
5. Attend to visual directions (note details on visual instructions worksheet)
- approaches materials left-to-right
- follows simple model
- looks for instructions before beginning activities
Counseling & Advisory (C) 8, 9, 10 (Circle One)
151
date date date date date Matching and Sorting
1. Complete inset puzzles
- up to 6 pieces
- 6 or more pieces
2. Sort 2 dissimilar objects
- with self-correcting container organization format
- to sample, with open containers
3. Sort (into containers) items for 1 visual dimension (object, color, shape)
- field of 2-6
- field of 6+
4. Match (onto surface) items for 1 visual dimension (object, color, shape)
- objects
- pictures
- field of 2-6 items
- field of 6+ items
5. Match/sort items for more than 1 visual dimension (object, color, shape,
details)
- objects or pictures
- field of 2-6 items
- field of 6+
6. Complete jig-saw puzzles (connecting pieces)
- up to 6 pieces
- 6+ pieces
7. Match objects to pictures (or reverse)
- identical match
- non-identical
- field of 2-6 items
- field of 6+
Counseling & Advisory (C) 8, 9, 10 (Circle One)
152
date date date date date 8. Assemble stacking/nesting toys by size
- up to 4 pieces
- 4+ pieces
9. Sort items into categories by polar concept
- big/little
- clean/dirty
- good/broken
- hard/soft
- wet/dry
- hot/cold
10. Sort items into functional categories
- field of 2 categories (foods, clothing, people, animals, vehicles, toys)
- field of 3-4 categories (as above)
- sub-categories (rooms of the home, wild v. tame animals, clothing
for seasons, girls v. boys, etc.)
11. Match items by functional association
- pair things that go together
Number and Quantity Concepts
1. Place items in 1:1 correspondence
- self-correcting, into fitted space
- onto visual cue
2. Match/sort numerals
- 1-5
- up to 10
- 10+
Counseling & Advisory (C) 8, 9, 10 (Circle One)
153
date date date date date 3. Identify numerals
- in order
- out of order
- 1-5
- up to 10
- 10+
4. Count sets of objects and match to numeral
- 1-5
- up to 10
- 10+
5. Create/give sets of objects for numerals
- 1-5
- up to 10
- 10+
6. Place numerals in order
- 1-5
- up to 10
- 10+
7. Fill in missing numerals in sequence
- 1-5
- up to 10
- 10+
Counseling & Advisory (C) 8, 9, 10 (Circle One)
154
date date date date date Pre-reading
1. Match/sort alphabet letters
- identical
- non-identical but all same case
- upper case and lower case
2. Place alphabet letters in order
- fills in missing letters in alphabetical sequence
- creates alphabetical sequence
3. Match letters sequentially to duplicate words
- match letters with left-to-right sequence to form words
- match pre-written short words
4. Identify own printed name
- from field of 2
- across a variety of settings
5. Match/sort short words
- high use such as names, colors, schedule, etc.
- high interest such as toys, foods, pets, etc.
6. Match (read) sight words to objects or pictures
- high use such as names, colors, schedule, etc.
- high interest such as toys, foods, pets, etc.
7. Read/follow simple 1-2 word printed directions (read for information)
- go get item
- place item in location
- perform action with object
- give item to person
Counseling & Advisory (C) 8, 9, 10 (Circle One)
155
Expressive Communication
date (8th
) date (9th) date (10
th) date (11
th) date (12
th)
1. Cooperate in routines with adult (adult builds routine based on child‘s
interests)
- movement and sensory activities
swinging, tickling, deep pressure, etc.
- use of interesting toys/materials
roll cars, play xylophone, wind-up toys, balloon, etc.
- vocal/verbal routine
sing song, finger play, counting, etc.
2. Anticipate/participate in routines as above (some joint attention, eye
contact, spontaneous participation)
- movement and sensory activities
- use of toys and materials
- vocal/verbal routines
3. Indicate desire for routines (as above) to continue if disrupted
- attempt to restart routine motorically
- attempt to restart routine using materials
- attempt to restart routine vocally or with gestures
4. Seek attention of adults for play or assistance
- approach and/or eye gaze
- use physical contact
- use materials
- use gestures or vocalizations
5. Refuse objects/reject actions (non-preferred food, toy, activity)
- use physical contact/pushing away
- use gestures or vocalizations
6. Request by guiding adult hand to desired objects, actions, locations
- for objects, actions, locations
Counseling & Advisory (C) 8, 9, 10 (Circle One)
156
date date date date date 7. Request using object exchange
- foods, toys, activities, songs
8. Request using picture exchange
- foods, toys, activities, songs, people
- note if photos, labels, drawings, icons
9. Indicate choices using object exchange
- foods, toys, activities, songs, etc.
- note # of options
10. Indicate choices using picture exchange
- foods, toys, activities, songs, etc.
- note # of options and if photos, labels, drawings, or icons
11. Indicate choices using printed words
- foods, toys, activities, songs, etc.
- note # of options
12. Direct activity by indicating next steps
- note system used (motor/gesture/objects/pictures, etc.)
- note # of steps
13. Seek help and/or permission
- note system used (as above)
14. Seek information about things in surroundings
- what things are, how things work, where things are
- note system used
Counseling & Advisory (C) 8, 9, 10 (Circle One)
157
date date date date date 15. Show persistence in communication strategies
- initiate without prompting
- attract and maintain attention
- repeat message
16. Direct gestures and facial expressions to clarify communication
- point, nod/shake head
- smile, frown, puzzled, icky, shrug, etc.
17. Seek to repair miscommunication with alternate strategy
- seek proximity and eye gaze
- volume
- gesture/pantomime
18. Use spoken words to communicate basic needs and wishes (note
use of visual supports for teaching, independence, and back-up)
- request
for objects, people, activities, locations, etc.
for possession (mine, gimme)
for recurrence (more, again)
- make choices
note size of array choosing from
- reject/refuse
no, not, stop, don‘t, etc.
- accept/agree
yes, OK, alright
- direct activities
note # of steps
- seek information/assistance/permission
use of intonation patterns
question forms
Counseling & Advisory (C) 8, 9, 10 (Circle One)
158
date date date date date 19. Use spoken words to comment
- comment to others about objects
- comment to others about surroundings/activities
- share information about current activity
20. Use spoken words for simple interactions with others
- greetings and farewells
- to invite to join in activity
- to show/share materials/activity
21. Language includes variety of grammatical categories
- nouns, including names
- actions and other verbs
- location words and phrases
- attributes/descriptors/category words
Counseling & Advisory (C) 8, 9, 10 (Circle One)
159
READINESS SKILLS CHECKLIST KEY
F=Full assistance
M=Moderate assistance
E=Emerging Independence
I=Independent
BASIC WORK SKILLS DATE DATE DATE DATE
1. Attends to verbal directions
-independently
-with prompts
2. Attends to visual directions
-focuses on job
-independently
-with prompts
-approaches materials from left-to-right
-follows a simple model
-scans materials
3. Attends to materials
-scans for materials
- all materials are used
-indicates finished product
4. Works to completion of activity
-work endurance 0-5 minutes
-work endurance 5-10 minutes
-work endurance 10-20 minutes
-work endurance 20-30 minutes
-work endurance 30 minutes or more
Counseling & Advisory (C) 8, 9, 10 (Circle One)
160
Adapted from TEACCH curriculum workbooks/TTAP 7/7/09.vsb
Counseling & Advisory (C) 8, 9, 10 (Circle One)
161
READINESS SKILLS CHECKLIST II KEY
F=Full assistance
M=Moderate assistance
E=Emerging Independence
I=Independent
MATCHING AND SORTING DATE DATE DATE DATE
1. Matching
-colors in a field of 2
-colors in a field of 3
-objects in a field of 2
-objects in a field of 3
-shapes in a field of 2
-shapes in a field of 3
2. Sorting
-colors in a field of 4
-objects in a field of 4
-sorts dissimilar objects
-sorts by similar category
-sorts into category by polar concept (big/little, hard/sort)
-sorts by functional category (food, clothing, people)
4. Assembly
-stacking
-collating (3 papers/cards)
-follows a simple pattern
-assembly of items (2 pieces)
-assembly of items (3-5 pieces)
Counseling & Advisory (C) 8, 9, 10 (Circle One)
162
Adapted from TEACCH curriculum workbooks/TTAP 7/7/09.vsb
Counseling & Advisory (A) 8, 9, 10,
11, 12 (Circle One)
Student: ___________________________________________________________________________
163
READINESS SKILLS CHECKLIST III KEY
F=Full assistance
M=Moderate assistance
E=Emerging Independence
I=Independent
NUMBER AND QUANTITY CONCEPTS DATE DATE DATE DATE
1. Place items in 1:1 correspondence
2. Matching
-single digit numbers
-double digit numbers
3. Sorting
-single digit numbers
-double digit numbers
4. Identification of numerals
-in order single digit numbers
-in order double digit numbers
-out of order single digit numbers
-out of order double digit numbers
5. Count sets of objects
-1-5
-up to 10
-by dozens
Counseling & Advisory (A) 8, 9, 10,
11, 12 (Circle One)
Student: ___________________________________________________________________________
164
6. Packages objects
-independently
-with a template
-single items
-2-5 items
-6+ items Adapted from TEACCH curriculum workbooks/TTAP 7/7/09.vsb
Student: _____________________________________________________________________
165
READINESS SKILLS CHECKLIST IV KEY
F=Full assistance
M=moderate assistance
E=Emerging Independence
I=Independent
PRE-READING DATE DATE DATE DATE
1. Match/sort alphabet letters
-identical
-non-identical but all the same case
-upper and lower case
-creates alphabetical sequence
-filing by alphabetically
-collating alphabetically
2. Match letters sequentially to duplicate words
-match letters with left-to-right sequence to form words
-match cursive writing to printed word
3. Identify own printed name
-from a field of 2
-from a field of 5
-across a variety of settings
5. Match (read) sight words to objects or pictures
-high use words such as names, colors, schedule, etc.
up to 5 words
+10 words
+25 words
Student: _____________________________________________________________________
166
+ over 26 words
6. Read/follow simple 1-2 word directions
-get item and give the item to a person
-perform an action with an item Adapted from TEACCH curriculum workbooks/TTAP 7/7/09.vsb
Student: _____________________________________________________________________
167
Interview Questions
Name: Date:
What do you like to do?
What do you do well?
What are your needs?
Leisure
Leisure
School
Community
Family
Work
Other
Team Player
Punctual
Friendly
Good Worker
Other
Listen
Communication
Transportation
Learning
Personal Care
Support
Other
Student: _____________________________________________________________________
168
Retail
What work experiences have you had?
What work experiences have you had?
Food Service
Custodial
Clerical
Landscaping
Other
What work experiences did you like?
What work experiences have you had? Retail
Food Service
Custodial
Clerical
Landscaping
Other
What work experiences did you not like?
What work experiences have you had? Retail
Food Service
Custodial
Clerical
Landscaping
Other
What would you like to do after high school?
What work experiences have you had? Work
Independent Living
Adult Education
Friends
Leisure
Other
Counseling & Advisory (A) 9, 10, 11, 12 (Circle One)
Student: ____________________________________________________________________
169
GROUP SKILLS CHECKLIST KEY
F=Full assistance
M=Moderate assistance
E=Emerging Independence
I=Independent
BASIC GROUP SKILLS DATE DATE DATE DATE
1. Approach structured group activity for short periods of time
2. Stay with the group for a short activity (1-5 minutes)
3. Respond to name and give appropriate greetings
-with prompts
-independently
4. Participate actively with a group activity
-demonstrate positive behavior with familiar people
-demonstrate positive behavior with strangers
-wait appropriately
-take turns appropriately
-shares objects appropriately
-engage in a leisure activity with peers
5. Respond appropriately to physical contact with others
6. Work cooperatively with peers and adults
-share materials
-acknowledge peers
-understand and accept authority figures
-ask for assistance appropriately
Counseling & Advisory (A) 9, 10, 11, 12 (Circle One)
Student: ____________________________________________________________________
170
-follow visual rules
-follow verbal rules
Adapted from TEACCH curriculum workbooks/TTAP 7/7/09.vsb
Counseling & Advisory (A) 9, 10,
11, 12 (Circle One)
Student:_____________________________________________________________________
171
SOCIAL SKILLS CHECKLIST KEY
F=Full assistance
M=Moderate assistance
E=Emerging Independence
I=Independent
BASIC SOCIAL SKILLS DATE DATE DATE DATE
1. Engage in a leisure activity in proximity to adults
2. Engage in a leisure activity in proximity to peers
-tolerate noise and movement without avoiding/becoming upset
-in teacher-led activities
-in leisure activities
3. Respond to and cooperate with others (1-step)
-share/give out materials to peers with adult mediation
-respond to peer initiation with adult mediation
-observe/notice peers
4. Imitate
-use of objects/games
-body movements in leisure setting
-vocal/verbal imitation in leisure setting
5. Initiate contact with adults for leisure activities
6. Initiate contact with peers for leisure activities
7. Take turns with adults in leisure activities
Counseling & Advisory (A) 9, 10,
11, 12 (Circle One)
Student:_____________________________________________________________________
172
8. Take turns with peers in leisure activities
9. Follow simple rules for table and motor games
Adapted from TEACCH curriculum workbooks/TTAP 7/7/09.vsb
Counseling & Advisory (A) 9, 10,
11, 12 (Circle One)
Student:_____________________________________________________________________
173
VOCATIONAL SKILLS CHECKLIST KEY
F=Full assistance
M=Moderate assistance
E=Emerging Independence
I=Independent
VOCATIONAL SKILLS DATE DATE DATE DATE
1. Understands the work environment
-know what is expected each day
-be willing to work each day
-show respect for property, rules, and regulations at work
2. Communicate appropriately
-ask for assistance appropriately
-ask for directions
-work well in proximity of others
-recognize authority figures
3. Follows instructions verbally or visually
-attempts new tasks
-handles transitions well
-responds appropriately to directions
-tolerates interruptions
-adjusts to changes in routine
4. Endurance
-works with assistance
-works steadily
-works independently
-increase time on task from 10-20 minutes
from 20-30 minutes
Counseling & Advisory (A) 9, 10,
11, 12 (Circle One)
Student:_____________________________________________________________________
174
from 30-45 minutes
from 45-60 minutes
+60 minutes Adapted fro