Trial Work Assessment - Maine



Trial Work Evaluation (TWE) definition: FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ? A TWE is conducted with the goal of helping the VRC determine eligibility for an individual whose ability to benefit from VR services is uncertain. The document used for this is the Trial Work Experience/ Extended Evaluation form. This assessment will provide information about the individual’s skills, abilities, strengths, barriers and/or need for Long Term Support (LTS) in an employment setting. If the individual is not found to be work-ready, the VRC will refer the individual to other services that may help to be able to benefit from VR services in the future.NOTE: The expectation of the TWE is to use the information provided by the assessment to help determine eligibility for VR services and plan for future services. Required Information: To be Completed by the Employment Specialist (ES)Client Name: FORMTEXT ?????Report Date: FORMTEXT ?????Referring VRC: FORMTEXT ?????CRP/Agency: FORMTEXT ?????Employment Specialist: FORMTEXT ?????Job Coach: FORMTEXT ?????Purpose of Service: FORMTEXT ?????Assessment Site: FORMTEXT ?????Address: FORMTEXT ?????Assessment Date(s): FORMTEXT ?????Assessment Schedule: FORMTEXT ?????Client Job Position (Title): FORMTEXT ?????Total number of hours client worked during this assessment:Daily: FORMTEXT ?????Weekly: FORMTEXT ?????Total: FORMTEXT ?????Number of on-site job coaching hours required by client: FORMTEXT ?????Responsibilities of client’s job position: FORMTEXT ?????Expectations of employer: FORMTEXT ?????Medications: Do they interfere with individual’s ability to attend work, complete work tasks, concentrate, operate heavy machinery, and/or communicate? FORMTEXT ?????Vision: Does the individual have difficulty seeing which affects their ability to attend work, complete work tasks, concentrate and communicate? FORMTEXT ?????Hearing: Does the individual have difficulty hearing which affects their ability to attend work, complete work tasks, concentrate and communicate? FORMTEXT ?????Mobility: FORMTEXT ?Does the individual have difficulty with mobility which affects their ability to attend work, complete work tasks, and safely move through the work environment as needed? FORMTEXT ?????Mark all applicable responses for each of the following and include comments regarding client’s performance and any accommodations which were provided. If not applicable, please type “N/A” in the comment section. FORMTEXT ? FORMTEXT ?Transportation availability: FORMCHECKBOX Transportation from outsider. FORMCHECKBOX Available from others within limits. (Please specify limits below) FORMCHECKBOX Available from others, flexible. FORMCHECKBOX Provides own transportation. FORMCHECKBOX Transportation ments: FORMTEXT ?????Independence regarding arranging transportation: FORMCHECKBOX Requires assistance. FORMCHECKBOX Must be picked up and left off. FORMCHECKBOX Independent with reminders. FORMCHECKBOX ments: FORMTEXT ?????Flexibility in working hours: FORMCHECKBOX No Flexibility. FORMCHECKBOX Some, but requires approval from other. (i.e. guardian, residential staff, adherence to court order) FORMCHECKBOX Health related considerations. FORMCHECKBOX Adaptable to most ments: FORMTEXT ?????Health maintenance (eating, sleeping, hygiene, etc…): FORMCHECKBOX Habits likely to negatively impact other workers. FORMCHECKBOX Habits likely to interfere with attendance. FORMCHECKBOX Health maintenance not likely to interfere with ments: FORMTEXT ?????Family/significant other’s support for work and rehabilitation: FORMCHECKBOX Actively antagonistic 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 ments: FORMTEXT ?????Work FORMTEXT ?PerformanceWork orientation: FORMCHECKBOX States or demonstrates desire not to work. FORMCHECKBOX Demonstrates ambivalence about work. FORMCHECKBOX Desire to work at some point in the future is indicated. FORMCHECKBOX Demonstrates desire to work ments: FORMTEXT ?????Work initiative: FORMCHECKBOX Avoids work even after assigned. FORMCHECKBOX Accepts work once assigned. FORMCHECKBOX Initiates preferred work. FORMCHECKBOX Seeks work/meaningful activity when assigned tasks are ments: FORMTEXT ?????Orientation to work site: FORMCHECKBOX Needs assistance after orientation training. FORMCHECKBOX Orients well to room/work area. FORMCHECKBOX Orients to building and ments: FORMTEXT ?????Attendance: (Based on 20 hour assessment) FORMCHECKBOX Absent 2+ days from TWE for reason not acceptable to the employer. FORMCHECKBOX Absent 2+ days from TWE for bona fide reasons. FORMCHECKBOX Required support and encouragement to achieve 18-20 hours of TWE. FORMCHECKBOX Attended all scheduled hours of ments: FORMTEXT ?????Promptness: FORMCHECKBOX Is late for reasons unacceptable to the employer. FORMCHECKBOX Is late for a bona fide reason. FORMCHECKBOX Requires support and encouragement to be prompt. FORMCHECKBOX Self-monitors ments: FORMTEXT ?????Appearance: FORMCHECKBOX Unkempt. Poor hygiene. FORMCHECKBOX Unkempt. Clean. FORMCHECKBOX Neat and clean. Clothing unmatched or inappropriate clothing. FORMCHECKBOX Neat and clean. Clothing matched and appropriate to ments: FORMTEXT ?????Interaction with co-workers, employer and public: FORMCHECKBOX Does not respond appropriately to working with or in proximity to other people. FORMCHECKBOX Adapts to working with one other person. FORMCHECKBOX Adapts to working with several other people. FORMCHECKBOX Works effectively in groups. FORMCHECKBOX Works better alone. FORMCHECKBOX Works well with ments: FORMTEXT ?????Interaction with supervisors: 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 ments: FORMTEXT ?????Reinforcement needs: FORMCHECKBOX Requires continued reinforcement. FORMCHECKBOX Requires intermittent reinforcement. FORMCHECKBOX Responds to natural ments: FORMTEXT ?????Work productivity: 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 ments: FORMTEXT ?????Work quality: 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 ments: FORMTEXT ?????Independence regarding work performance: FORMCHECKBOX Requires supervision at all times. FORMCHECKBOX Requires frequent supervision. FORMCHECKBOX Independent with reminders to stay on task. FORMCHECKBOX ments: FORMTEXT ?????Handling of constructive criticism: FORMCHECKBOX Demonstrates resistance. Becomes argumentative. FORMCHECKBOX Neither responds nor changes behavior. FORMCHECKBOX Acknowledges criticism; responds by withdrawal from tasks. FORMCHECKBOX Makes requested changes in ments: FORMTEXT ?????Aggressive actions or speech: FORMCHECKBOX Hourly. FORMCHECKBOX Daily. FORMCHECKBOX Weekly/Monthly. FORMCHECKBOX Not at ments: FORMTEXT ?????Ability to follow directions: 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 steps without ments: FORMTEXT ?????Adaptability: FORMCHECKBOX Requires a rigid routine. FORMCHECKBOX Adapts to consistent routine after orientation. FORMCHECKBOX Adapts to changes in routine with orientation. FORMCHECKBOX Adapts to change on ments: FORMTEXT ?????Time skills: 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 ments: FORMTEXT ?????Reading skills: FORMCHECKBOX Recognizes characters (single numbers or letters) and pictures. Qualify: cursive or block, etc. FORMCHECKBOX Reads words and phrases. Qualify: cursive, block, etc. FORMCHECKBOX Reads simple sentences. Qualify: cursive, block, etc. FORMCHECKBOX Proficient reading ments: FORMTEXT ?????Money skills: FORMCHECKBOX Does not demonstrate money concepts. FORMCHECKBOX Conducts money exchanges, able to recognize the relative value of coins and bills. FORMCHECKBOX Recognizes the relative value of coins and bills, but does not make change. FORMCHECKBOX Conducts money exchanges and makes ments: FORMTEXT ?????Writing skills: FORMCHECKBOX Writes characters (single numbers or letters) and pictures. FORMCHECKBOX Writes words and phrases. Qualify: cursive, block, etc. FORMCHECKBOX Writes simple sentences. Qualify: cursive, block, etc. FORMCHECKBOX Writes ments: FORMTEXT ?????Math skills: FORMCHECKBOX Does not understand number concepts (numeric relativity). FORMCHECKBOX Counts. FORMCHECKBOX Counts and adds. FORMCHECKBOX Adds and subtracts. FORMCHECKBOX Understands measurement concepts. FORMCHECKBOX Demonstrated ability to do complex ments: FORMTEXT ?????Computer proficiency: FORMCHECKBOX Can clock in and out for work. FORMCHECKBOX Can turn computer on. FORMCHECKBOX Is able to navigate/browse the internet. FORMCHECKBOX Is able to use Microsoft Word and/or other ments: FORMTEXT ?????Copying data: FORMCHECKBOX Does not copy numbers/letters. FORMCHECKBOX Copies numbers/letters, but needs large spaces. FORMCHECKBOX Copies numbers/letters but has difficulty with sizing and placement. FORMCHECKBOX Copies numbers/letters in appropriate ments: FORMTEXT ?????Comparing data: FORMCHECKBOX Unable to demonstrate the making of comparative judgments. FORMCHECKBOX Ability to demonstrate the making of comparative judgments. FORMCHECKBOX Ability to compare data and things and make judgments requiring classification of two or more ments: FORMTEXT ?????Communication – speaking/gesturing/signing: FORMCHECKBOX Gestures or sounds are only understandable to persons thoroughly familiar with person. FORMCHECKBOX Information provided by simple gestures or signs is understandable to CRP & co-workers. FORMCHECKBOX Information provided by simple sign or word is understandable to CRP & co-workers. FORMCHECKBOX Can speak/sign using simple phrases. FORMCHECKBOX Demonstrates fluent ments: FORMTEXT ?????Providing Assistance: FORMCHECKBOX Responds to gestures and demonstration of help needed by people. FORMCHECKBOX Responds in courteous manner to verbal requests to assist. FORMCHECKBOX Initiates providing assistance to ments: FORMTEXT ?????Worker safety: (Ability to understand and follow safety rules.) FORMTEXT ? FORMCHECKBOX Unaware of safety as a component of the job and requires close supervision. FORMCHECKBOX Recognizes safety as a component of the job, intermittent supervision required. FORMCHECKBOX Recognizes safety as a component of the job and demonstrates alertness to potential ments: FORMTEXT ?????Environmental considerations (Ability to tolerate the following conditions): FORMTEXT ? FORMCHECKBOX Tolerance to cold. FORMCHECKBOX Tolerance to heat. FORMCHECKBOX Tolerance to humidity. FORMCHECKBOX Tolerance to scents. FORMCHECKBOX Tolerance to chemicals. FORMCHECKBOX ments: FORMTEXT ?????Describe accommodations needed: FORMTEXT ?????Additional comments: FORMTEXT ????? FORMTEXT ?????Employment Specialist SignatureDate ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download