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Example 4 - This planning template was designed by two special education teachers (Kerry Walker and Alicia Matthews) and is currently being used in Rhode Island.Pre-Planning WorksheetsEssential Activities and Necessities:EssentialActivities(examples)FrequencyLevel ofSupportWho ProvidesSupportTransportationCostSource of FundsClean houseGo shoppingDo laundryShowerMedicationRecreational ActivitiesFrequencyLevel ofSupportWho ProvidesSupportTransportationCostSource of FundsWork Related ActivitiesFrequencyLevel ofSupportWho ProvidesSupportTransportationCostSource of FundsWhat would a typical week day look?Level ofSupportWho ProvidesSupportTransportationCostSource of Funds12:00–1:00 AM1:00 – 2:00 AM2:00 – 3:00 AM3:00 – 4:00 AM4:00 – 5:00 AM5:00 – 6:00 AM6:00 – 7:00 AM7:00 – 8:00 AM8:00 – 9:00 AM9:00 –10:00 AM10:00–11:00AM11:00–12:00PM12:00–1:00 PM1:00 – 2:00 PM2:00 – 3:00 PM3:00 – 4:00 PM4:00 – 5:00 PM5:00 – 6:00 PM6:00 – 7:00 PM7:00 – 8:00 PM8:00 – 9:00 PM9:00 –10:00 PM10:00–11:00PM11:00–12:00AMWhat would a typical week end day look?Level ofSupportWho ProvidesSupportTransportationCostSource of Funds12:00–1:00 AM1:00 – 2:00 AM2:00 – 3:00 AM3:00 – 4:00 AM4:00 – 5:00 AM5:00 – 6:00 AM6:00 – 7:00 AM7:00 – 8:00 AM8:00 – 9:00 AM9:00 –10:00 AM10:00–11:00AM11:00–12:00PM12:00–1:00 PM1:00 – 2:00 PM2:00 – 3:00 PM3:00 – 4:00 PM4:00 – 5:00 PM5:00 – 6:00 PM6:00 – 7:00 PM7:00 – 8:00 PM8:00 – 9:00 PM9:00 –10:00 PM10:00–11:00PM11:00–12:00AMGoal Sheet SummaryGoal:What are the action steps?When will it happen?Who will provide support?What kind of support id needed?When is support needed? For some or all of the activity? What parts?How will the person get there?Is there a cost? Where will the funds come from?What data will be recorded? How?Progress MonitoringCurrent Skills1st Check In2nd Check In3rd Check In4th Check InBelowExpectationLess Than ExpectedExpectedExceedsExpectationFar Above ExpectationSatisfaction ................
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