Community-Based Situational Assessment (CBSA) and Trial ...



Community-Based Situational Assessment (CBSA) and Trial Work Evaluation (TWE)Multi-Use Form FORMTEXT ?This multi-use form was developed to avoid duplication and confusion with multiple forms and provide a means to streamline the reporting process. The CBSA and TWE each have similarities but differ in purpose. If you have been asked to conduct a TWE, please speak to the VR Counselor about how you may adapt this form to that process. FORMTEXT ? FORMTEXT ? FORMTEXT ?CBSAA Community-based Situational Assessment or CBSA is utilized to assess a client’s skills, abilities, strengths, barriers, and need for long term support in a competitive work environment. In a CBSA, the Employment Specialist would determine what, if any additional support might be needed for the client to be successful. The Vocational Rehabilitation Counselor (VRC) may be reasonably certain a client has the skills for a specific job, but may be unsure of what services might be necessary to best insure the client’s success over time. It is often necessary to evaluate the client’s abilities to meet those demands by observing him/her in the actual work environment. A CBSA also provides the employer an opportunity to see a client “in action”. A job offer may be an outcome of the SA, in which case, the information gathered will be utilized to create the Individualized Plan for Employment (IPE). FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ? This multi-use form is not required when conducting an Assessment to Hire. FORMTEXT ? Required Information:Client Name: FORMTEXT ?????Report Date: FORMTEXT ?????Referring VRC: FORMTEXT ?????CRP/Agency: FORMTEXT ?????Employment Specialist: FORMTEXT ?????Job Coach: FORMTEXT ?????Purpose of Service: FORMTEXT ?????Assessment Site and Address: FORMTEXT ?????Assessment Date(s): FORMTEXT ?????Assessment Schedule: FORMTEXT ?????Client Job Position (Title): FORMTEXT ?????Total number of hours client worked during assessment: Daily: FORMTEXT ?????Weekly: FORMTEXT ?????Total: FORMTEXT ?????Number of onsite, direct support/job coaching hours required during this assessment: FORMTEXT ?????Responsibilities of client’s job position: FORMTEXT ?????Billing InformationDate (when)Activity (who, what, where)Actual hours FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Wages: FORMTEXT ?????Total hours used: FORMTEXT ?????Future hours requested: FORMTEXT ?????Work Performance FORMTEXT ?Work Orientation( FORMCHECKBOX This behavior or action is not a component of this assessment and/or was not observed) A. Please describe in your own words, the behavior or actions that this individual demonstrates in the area of WorkInitiative. FORMTEXT ????? B. Which item(s) below best describes the comments/narrative you have written above: FORMTEXT ? FORMCHECKBOX Indicates or demonstrates does not want to work FORMCHECKBOX Demonstrates ambivalence about work. FORMCHECKBOX Desire to work at some point in the future indicated FORMCHECKBOX Demonstrates desire to work now 2. Work Initiative( FORMCHECKBOX This behavior or action is not a component of this assessment and/or was not observed) A. Please describe in your own words, the behavior or actions that this individual demonstrates in the area of WorkInitiative. FORMTEXT ????? B. Which item(s) below best describes the comments/narrative you have written above: FORMTEXT ? FORMCHECKBOX Avoids work even after assigned. FORMCHECKBOX Accepts work once assigned. FORMCHECKBOX Initiates preferred work FORMCHECKBOX Seeks work/meaning activity when assigned tasks are completed. 3. Orientation to Work Site( FORMCHECKBOX This behavior or action is not a component of this assessment and/or was not observed) A. Please describe in your own words, the behavior or actions that this individual demonstrates in the area of WorkInitiative. FORMTEXT ????? B. Which item(s) below best describes the comments/narrative you have written above: FORMTEXT ? FORMCHECKBOX Needs assistance after orientation training FORMCHECKBOX Orients well to room/work area. FORMCHECKBOX Orients to building & grounds 4. Work Productivity( FORMCHECKBOX This behavior or action is not a component of this assessment and/or was not observed) A. Please describe in your own words, the behavior or actions that this individual demonstrates in the area of WorkInitiative. FORMTEXT ????? B. Which item(s) below best describes the comments/narrative you have written above: FORMTEXT ? FORMCHECKBOX Unaware of speed as a component of job expectation. FORMCHECKBOX Recognizes speed as a component of job expectation but does not demonstrate effort and/or ability to improve. FORMCHECKBOX Recognizes speed as a component of job expectation and demonstrates efforts to meet and maintain expectations. 5. Work Quality( FORMCHECKBOX This behavior or action is not a component of this assessment and/or was not observed) A. Please describe in your own words, the behavior or actions that this individual demonstrates in the area of WorkInitiative. FORMTEXT ????? B. Which item(s) below best describes the comments/narrative you have written above: FORMTEXT ? FORMCHECKBOX Unaware of quality as a component of job expectation. FORMCHECKBOX Recognizes quality as a component of job expectation but does not demonstrate effort and/or ability to improve. FORMCHECKBOX Recognizes quality as a component of job expectation and demonstrates efforts to meet and maintain expectations.Additional Work Quality Observations FORMTEXT ?( FORMCHECKBOX These behaviors or actions are not a component of this assessment and/or were not observed)Work Pace :Fast FORMCHECKBOX Moderate FORMCHECKBOX Slow FORMCHECKBOX Work Schedule:Intermittent FORMCHECKBOX Steady FORMCHECKBOX StaminaHigh FORMCHECKBOX Medium FORMCHECKBOX Low FORMCHECKBOX Arrival to WorkEarly FORMCHECKBOX Timely FORMCHECKBOX Late FORMCHECKBOX Departure from WorkEarly FORMCHECKBOX Timely FORMCHECKBOX Late FORMCHECKBOX Appropriate BreaksAlways FORMCHECKBOX Sometimes FORMCHECKBOX Never FORMCHECKBOX Ability to Recognize SurroundingsAlways FORMCHECKBOX Sometimes FORMCHECKBOX Never FORMCHECKBOX Ability to Work Safely and IndependentlyAlways FORMCHECKBOX Sometimes FORMCHECKBOX Never FORMCHECKBOX Comments: FORMTEXT ?????____________________________________________________________________________________________________________________________________________________________________________________________6. Independence Regarding Work Performance( FORMCHECKBOX This behavior or action is not a component of this assessment and/or was not observed) A. Please describe in your own words, the behavior or actions that this individual demonstrates in the area of WorkInitiative. FORMTEXT ????? B. Which item(s) below best describes the comments/narrative you have written above: FORMTEXT ? FORMCHECKBOX Requires supervision at all times. FORMCHECKBOX Requires frequent supervision. FORMCHECKBOX Independent with reminders to stay on task. FORMCHECKBOX Independent. 7. Ability to Follow Directions ( FORMCHECKBOX This behavior or action is not a component of this assessment and/or was not observed) A. Please describe in your own words, the behavior or actions that this individual demonstrates in the area of WorkInitiative. FORMTEXT ????? B. Which item(s) below best describes the comments/narrative you have written above: FORMTEXT ? FORMCHECKBOX Carries out 1 step with cues. FORMCHECKBOX Carries out 1 step without cues. FORMCHECKBOX Carries out multiple steps with cues. FORMCHECKBOX Carries out multiple tasks without cues. 8. Adaptability( FORMCHECKBOX This behavior or action is not a component of this assessment and/or was not observed) A. Please describe in your own words, the behavior or actions that this individual demonstrates in the area of WorkInitiative. FORMTEXT ????? B. Which item(s) below best describes the comments/narrative you have written above: FORMTEXT ? FORMCHECKBOX Requires rigid routine. FORMCHECKBOX Adapts to consistent routine after orientation. FORMCHECKBOX Adapts to changes in routine with orientation. FORMCHECKBOX Adapts to change on request. 9. Computer Proficiency( FORMCHECKBOX This behavior or action is not a component of this assessment and/or was not observed) A. Please describe in your own words, the behavior or actions that this individual demonstrates in the area of WorkInitiative. FORMTEXT ????? B. Which item(s) below best describes the comments/narrative you have written above: FORMTEXT ? FORMCHECKBOX Can clock in and out for work. FORMCHECKBOX Can’t turn computer on. FORMCHECKBOX Is able to navigate/browse the internet. FORMCHECKBOX Is able to use Microsoft Word and/or other software. 10. Comparing Data( FORMCHECKBOX This behavior or action is not a component of this assessment and/or was not observed) A. Please describe in your own words, the behavior or actions that this individual demonstrates in the area of WorkInitiative. FORMTEXT ?????B. Which item(s) below best describes the comments/narrative you have written above: FORMTEXT ? FORMCHECKBOX Unable to demonstrate making comparative judgments FORMCHECKBOX Ability to demonstrate making comparative judgements FORMCHECKBOX Ability to compare data & things & make judgments requiring classification of two or more categories 11. Worker Safety( FORMCHECKBOX This behavior or action is not a component of this assessment and/or was not observed) A. Please describe in your own words, the behavior or actions that this individual demonstrates in the area of WorkInitiative. FORMTEXT ????? B. Which item(s) below best describes the comments/narrative you have written above: FORMTEXT ? FORMCHECKBOX Unaware of safety as a job component, requires close supervision FORMCHECKBOX Recognizes safety as a job component, intermittent supervision required FORMCHECKBOX Recognizes safety as a job component, demonstrates alertness to potential hazards 12. Flexibility in Work Hours( FORMCHECKBOX This behavior or action is not a component of this assessment and/or was not observed) A. Please describe in your own words, the behavior or actions that this individual demonstrates in the area of WorkInitiative. FORMTEXT ????? B. Which item(s) below best describes the comments/narrative you have written above: FORMTEXT ? FORMCHECKBOX No flexibility FORMCHECKBOX Some, requires approval from other (i.e. guardian, residential staff, adherence to court order, etc.) FORMCHECKBOX Health related considerations. FORMCHECKBOX Adaptable to most hours 13. Environmental Considerations (Ability to tolerate the environmental conditions in the workplace( FORMCHECKBOX This behavior or action is not a component of this assessment and/or was not observed) A. Please describe in your own words, the behavior or actions that this individual demonstrates in the area of WorkInitiative. FORMTEXT ????? B. Which item(s) below best describes the comments/narrative you have written above: FORMTEXT ? FORMCHECKBOX Tolerance to cold FORMCHECKBOX Tolerance to heat FORMCHECKBOX Tolerance to humidity FORMCHECKBOX Tolerance to scents FORMCHECKBOX Tolerance to chemicals FORMCHECKBOX Tolerance to light FORMCHECKBOX Tolerance to noise FORMCHECKBOX Tolerance to vibration FORMCHECKBOX Other FORMTEXT ?????__________________ 14. Health Maintenance (habits such as eating, sleeping, hygiene, etc.)( FORMCHECKBOX This behavior or action is not a component of this assessment and/or was not observed) A. Please describe in your own words, the behavior or actions that this individual demonstrates in the area of WorkInitiative. FORMTEXT ?????B. Which item(s) below best describes the comments/narrative you have written above: FORMTEXT ? FORMCHECKBOX Likely to negatively impact other workers FORMCHECKBOX Likely to interfere with attendance FORMCHECKBOX Not likely to interfere with job15. Standing( FORMCHECKBOX This behavior or action is not a component of this assessment and/or was not observed) A. Please describe in your own words, the behavior or actions that this individual demonstrates in the area of WorkInitiative. FORMTEXT ????? B. Which item(s) below best describes the comments/narrative you have written above: FORMTEXT ? FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX Constant 16. Walking( FORMCHECKBOX This behavior or action is not a component of this assessment and/or was not observed) A. Please describe in your own words, the behavior or actions that this individual demonstrates in the area of WorkInitiative. FORMTEXT ????? B. Which item(s) below best describes the comments/narrative you have written above: FORMTEXT ? FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX Constant 17. Sitting( FORMCHECKBOX This behavior or action is not a component of this assessment and/or was not observed) A. Please describe in your own words, the behavior or actions that this individual demonstrates in the area of WorkInitiative. FORMTEXT ????? B. Which item(s) below best describes the comments/narrative you have written above: FORMTEXT ? FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX Constant 18. Driving( FORMCHECKBOX This behavior or action is not a component of this assessment and/or was not observed) A. Please describe in your own words, the behavior or actions that this individual demonstrates in the area of WorkInitiative. FORMTEXT ????? B. Which item(s) below best describes the comments/narrative you have written above: FORMTEXT ? FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX Constant 19. Lifting( FORMCHECKBOX This behavior or action is not a component of this assessment and/or was not observed) A. Please describe in your own words, the behavior or actions that this individual demonstrates in the area of WorkInitiative. FORMTEXT ????? B. Which item(s) below best describes the comments/narrative you have written above: FORMTEXT ? FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX Constant 20. Carrying( FORMCHECKBOX This behavior or action is not a component of this assessment and/or was not observed) A. Please describe in your own words, the behavior or actions that this individual demonstrates in the area of WorkInitiative. FORMTEXT ????? B. Which item(s) below best describes the comments/narrative you have written above: FORMTEXT ? FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX Constant 21. Pushing( FORMCHECKBOX This behavior or action is not a component of this assessment and/or was not observed) A. Please describe in your own words, the behavior or actions that this individual demonstrates in the area of WorkInitiative. FORMTEXT ????? B. Which item(s) below best describes the comments/narrative you have written above: FORMTEXT ? FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX Constant22. Pulling( FORMCHECKBOX This behavior or action is not a component of this assessment and/or was not observed) A. Please describe in your own words, the behavior or actions that this individual demonstrates in the area of WorkInitiative. FORMTEXT ????? B. Which item(s) below best describes the comments/narrative you have written above: FORMTEXT ? FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX Constant 23. Climbing( FORMCHECKBOX This behavior or action is not a component of this assessment and/or was not observed) A. Please describe in your own words, the behavior or actions that this individual demonstrates in the area of WorkInitiative. FORMTEXT ????? B. Which item(s) below best describes the comments/narrative you have written above: FORMTEXT ? FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX Constant 24. Balancing( FORMCHECKBOX This behavior or action is not a component of this assessment and/or was not observed) A. Please describe in your own words, the behavior or actions that this individual demonstrates in the area of WorkInitiative. FORMTEXT ????? B. Which item(s) below best describes the comments/narrative you have written above: FORMTEXT ? FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX Constant 25. Stooping( FORMCHECKBOX This behavior or action is not a component of this assessment and/or was not observed) A. Please describe in your own words, the behavior or actions that this individual demonstrates in the area of WorkInitiative. FORMTEXT ????? B. Which item(s) below best describes the comments/narrative you have written above: FORMTEXT ? FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX Constant 26. Kneeling( FORMCHECKBOX This behavior or action is not a component of this assessment and/or was not observed) A. Please describe in your own words, the behavior or actions that this individual demonstrates in the area of WorkInitiative. FORMTEXT ????? B. Which item(s) below best describes the comments/narrative you have written above: FORMTEXT ? FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX Constant 27. Crouching( FORMCHECKBOX This behavior or action is not a component of this assessment and/or was not observed) A. Please describe in your own words, the behavior or actions that this individual demonstrates in the area of WorkInitiative. FORMTEXT ????? B. Which item(s) below best describes the comments/narrative you have written above: FORMTEXT ? FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX Constant 28. Reaching( FORMCHECKBOX This behavior or action is not a component of this assessment and/or was not observed) A. Please describe in your own words, the behavior or actions that this individual demonstrates in the area of WorkInitiative. FORMTEXT ????? B. Which item(s) below best describes the comments/narrative you have written above: FORMTEXT ? FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX Constant 29. Communication( FORMCHECKBOX This behavior or action is not a component of this assessment and/or was not observed) A. Please describe in your own words, the behavior or actions that this individual demonstrates in the area of WorkInitiative. FORMTEXT ????? B. Which item(s) below best describes the comments/narrative you have written above: FORMTEXT ? FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX Constant 30.Hearing Required( FORMCHECKBOX This behavior or action is not a component of this assessment and/or was not observed) A. Please describe in your own words, the behavior or actions that this individual demonstrates in the area of WorkInitiative. FORMTEXT ?????B. Which item(s) below best describes the comments/narrative you have written above: FORMTEXT ? FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX Constant Interpersonal/Communication FORMTEXT ?31. Handling of Constructive Criticism( FORMCHECKBOX This behavior or action is not a component of this assessment and/or was not observed) A. Please describe in your own words, the behavior or actions that this individual demonstrates in the area of Handling.of Constructive Criticism: FORMTEXT ????? B. Which item(s) below best describes the comments/narrative you have written above: FORMTEXT ? FORMCHECKBOX Demonstrative resistance becomes argumentative FORMCHECKBOX Neither responds nor changes behavior FORMCHECKBOX Acknowledges criticism; responds by withdrawal from tasks FORMCHECKBOX Makes requested changes in behavior 32. Interaction with Co-workers, Employer and Public( FORMCHECKBOX This behavior or action is not a component of this assessment and/or was not observed)A. Please describe in your own words, the behavior or actions that this individual demonstrates in the area of Interaction with Co-workers, Employer and Public. FORMTEXT ?????B. Which item(s) below best describes the comments/narrative you have written above: FORMTEXT ? FORMCHECKBOX Works better alone FORMCHECKBOX Does not respond appropriately to working with or in proximity to other people FORMCHECKBOX Works effectively in groups FORMCHECKBOX Adapts to working with one other person FORMCHECKBOX Adapts to working with several other people FORMCHECKBOX Works well with public 33. Interaction with Supervisors( FORMCHECKBOX This behavior or action is not a component of this assessment and/or was not observed)A. Please describe in your own words, the behavior or actions that this individual demonstrates in the area of Interaction with Supervisors FORMTEXT ????? B. Which item(s) below best describes the comments/narrative you have written above: FORMTEXT ? FORMCHECKBOX Does not appear to understand supervisory role FORMCHECKBOX Resistance to supervisory requests FORMCHECKBOX Seeks to please but demands excessive time FORMCHECKBOX Demonstrates respect of supervisory role34. Providing Assistance( FORMCHECKBOX This behavior or action is not a component of this assessment and/or was not observed)A. Please describe in your own words, the behavior or actions that this individual demonstrates in the area ofProviding Assistance. FORMTEXT ????? B. Which item(s) below best describes the comments/narrative you have written above: FORMTEXT ? FORMCHECKBOX Responds to gestures and demonstration of help needed by people FORMCHECKBOX Initiates providing assistance to others FORMCHECKBOX Responds in courteous manner to verbal requests to assist Other Consideration35. Family/Significant other’s Support for Work and Rehabilitation( FORMCHECKBOX This behavior or action is not a component of this assessment and/or was not observed) A. Please describe in your own words, the behavior or actions that this individual demonstrates in the area ofFamily/Significant other’s Support for Work & Rehabilitation. FORMTEXT ????? B. Which item(s) below best describes the comments/narrative you have written above: FORMTEXT ? FORMCHECKBOX Not supportive to individual’s efforts to work FORMCHECKBOX Indifferent to individual’s efforts to work FORMCHECKBOX Inconsistent FORMCHECKBOX Supportive of the individual’s efforts to work FORMCHECKBOX Case manager, ASPIRE/TANF involvement Transportation36. Transportation Availability( FORMCHECKBOX This behavior or action is not a component of this assessment and/or was not observed) A. Please describe in your own words, the behavior or actions that this individual demonstrates in the area ofTransportation Availability. FORMTEXT ????? B. Which item(s) below best describes the comments/narrative you have written above: FORMTEXT ? FORMCHECKBOX Transportation from outsider FORMCHECKBOX Available from others within limits: Specify FORMTEXT ?????_____________________________ FORMCHECKBOX Available from others, flexible FORMCHECKBOX Provides own transportation FORMCHECKBOX Transportation unavailable 37. Independence Regarding Arranging Transportation( FORMCHECKBOX This behavior or action is not a component of this assessment and/or was not observed) A. Please describe in your own words, the behavior or actions that this individual demonstrates in the area ofIndependence Regarding Arranging Transportation. FORMTEXT ?????B. Which item(s) below best describes the comments/narrative you have written above: FORMTEXT ? FORMCHECKBOX Requires assistance FORMCHECKBOX Must be picked up and dropped off FORMCHECKBOX Independent with reminders FORMCHECKBOX Independent38. Reinforcement Needs( FORMCHECKBOX This behavior or action is not a component of this assessment and/or was not observed) A. Please describe in your own words, the behavior or actions that this individual demonstrates in the area ofReinforcement Needs FORMTEXT ????? B. Which item(s) below best describes the comments/narrative you have written above: FORMTEXT ? FORMCHECKBOX Requires continued reinforcement FORMCHECKBOX Requires intermittent reinforcement FORMCHECKBOX Responds to natural reinforcement 39. Time Skills( FORMCHECKBOX This behavior or action is not a component of this assessment and/or was not observed) A. Please describe in your own words, the behavior or actions that this individual demonstrates in the area of Time Skills. FORMTEXT ????? B. Which item(s) below best describes the comments/narrative you have written above: FORMTEXT ? FORMCHECKBOX Unaware of time functions FORMCHECKBOX Aware of time functions FORMCHECKBOX Able to complete required task in allotted time FORMCHECKBOX Needs additional time to complete required tasks 40. Money Skills( FORMCHECKBOX This behavior or action is not a component of this assessment and/or was not observed)A. Please describe in your own words, the behavior or actions that this individual demonstrates in the area of Money Skills FORMTEXT ????? B. Which item(s) below best describes the comments/narrative you have written above: FORMTEXT ? FORMCHECKBOX Does not demonstrate money concepts FORMCHECKBOX Conducts money exchanges, able to recognize the value of coins and bills FORMCHECKBOX Recognizes the value to coins and bills, but does not make change FORMCHECKBOX Conducts money exchange and makes change41. Math Skills( FORMCHECKBOX This behavior or action is not a component of this assessment and/or was not observed)A. Please describe in your own words, the behavior or actions that this individual demonstrates in the area of Math Skills FORMTEXT ????? B. Which item(s) below best describes the comments/narrative you have written above: FORMTEXT ? FORMCHECKBOX Does not understand number concepts FORMCHECKBOX Counts FORMCHECKBOX Counts and adds FORMCHECKBOX Add and subtracts FORMCHECKBOX Understands measurement concepts FORMCHECKBOX Demonstrated ability to do complex math42. Copying Data(? This behavior or action is not a component of this assessment and/or was not observed)A. Please describe in your own words, the behavior or actions that this individual demonstrates in the area of Copying Data FORMTEXT ????? B. Which item(s) below best describes the comments/narrative you have written above: FORMTEXT ? FORMCHECKBOX Does not copy numbers/letters FORMCHECKBOX Copies numbers/letters but needs large spaces FORMCHECKBOX Copies number/letters in appropriate spaces FORMCHECKBOX Copies numbers/letters but has difficulty with sizing and placement 43. Gross Motor Skills( FORMCHECKBOX This behavior or action is not a component of this assessment and/or was not observed) A. Please describe in your own words, the behavior or actions that this individual demonstrates in the area of Gross Motor Skills FORMTEXT ????? B. Which item(s) below best describes the comments/narrative you have written above: FORMTEXT ? FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX Constant44. Fine Motor Skills( FORMCHECKBOX This behavior or action is not a component of this assessment and/or was not observed)A. Please describe in your own words, the behavior or actions that this individual demonstrates in the area of Fine Motor Skills FORMTEXT ????? B. Which item(s) below best describes the comments/narrative you have written above: FORMTEXT ? FORMCHECKBOX Not present FORMCHECKBOX Occasional FORMCHECKBOX Frequent FORMCHECKBOX Constant 45. Aggressive Actions or Communication( FORMCHECKBOX This behavior or action is not a component of this assessment and/or was not observed)A. Please describe in your own words, the behavior or actions that this individual demonstrates in the area ofAggressive Actions or Communication FORMTEXT ????? B. Which item(s) below best describes the comments/narrative you have written above: FORMTEXT ? FORMCHECKBOX Not at all FORMCHECKBOX Hourly FORMCHECKBOX Daily FORMCHECKBOX Weekly/Monthly 46. Reading Skills( FORMCHECKBOX This behavior or action is not a component of this assessment and/or was not observed) A. Please describe in your own words, the behavior or actions that this individual demonstrates in the area of Reading Skills FORMTEXT ????? B. Which item(s) below best describes the comments/narrative you have written above: FORMTEXT ? FORMCHECKBOX Recognizes single numbers/letters/pictures- indicate- Cursive/Block FORMCHECKBOX Reads words/phrases- indicate- Cursive/Block FORMCHECKBOX Reads simple sentences indicate- Cursive/Block FORMCHECKBOX Proficient reading skills 47. Writing Skills( FORMCHECKBOX This behavior or action is not a component of this assessment and/or was not observed) A. Please describe in your own words, the behavior or actions that this individual demonstrates in the area of Writing Skills FORMTEXT ????? B. Which item(s) below best describes the comments/narrative you have written above: FORMTEXT ? FORMCHECKBOX Writes sentences (single numbers/letters) and picture FORMCHECKBOX Writes words and phrases- indicate-Cursive/Block FORMCHECKBOX Writes simple sentences- indicate- Cursive/Block FORMCHECKBOX Writes proficiently Identify client’s primary strengths: FORMTEXT ?????Identify client’s primary barriers to employment: FORMTEXT ?????Do you see the need for supported employment services (on and/or off-site)? Please detail reasons for recommendationsincluding number of hours of long term support recommended for this job position FORMTEXT ? FORMTEXT ?????Based on this assessment, do you believe this worksite/type of employment is a good fit for this client? Please explain. FORMTEXT ?????Additional notes if applicable: FORMTEXT ?????Employment Specialist Signature FORMTEXT ?????Date: FORMTEXT ????? ................
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