Bathroom Skills/Toilet Use - Structure...Bathroom Skills/Toilet Use Student name: IEP GOAL? Yes No...
Transcript of Bathroom Skills/Toilet Use - Structure...Bathroom Skills/Toilet Use Student name: IEP GOAL? Yes No...
Bathroom Skills/Toilet Use Student name: IEP GOAL? Yes No
5= Exceptional, independently completed 2= Emerging, 2 or more direct cues given
4= Proficient, 1-2 indirect clues given 1= Poor, step-by-step directions given
3= Satisfactory, 1 direct cue given NA= Not Applicable
Requests bathroom if during task Comments (Date and Separate)
Walks to bathroom by self (10’ behind)
Opens door and enters bathroom
Closes door/stall door
Stands in front of toilet
Removes fanny pack, if worn
Asks adult to leave if not needed
Turns facing away from toilet
Lowers necessary clothing
Sits on toilet w/ genitals over/in opening
Discharges in toilet only (no spill)
Wipes self until paper is clean
Stands up from toilet
Raises clothing
Fastens all buttons, zippers, and belt
Puts on fanny pack
Flushes toilet
Walks to sink
Turns on water
Wets, soaps, and washes hands adequately
Dries hands
Throws away an paper towel
Adjusts clothing, if needed
Leaves bathroom
Returns to previous activity
Requests assistance, if needed
STAFF RATIO
DATE AND INITIAL
INDEPENDENCE RATIO
Bus Use Student name: IEP GOAL? Yes No
5= Exceptional, independently completed 2= Emerging, 2 or more direct cues given
4= Proficient, 1-2 indirect clues given 1= Poor, step-by-step directions given
3= Satisfactory, 1 direct cue given NA= Not Applicable
Identifies correct time for bus Comments (Date and Separate)
Obtains all needed materials
Walks to bus stop
Arrives before bus (on time)
Waits for bus to arrive
Gets money in hand when bus is
visible
Boards bus
Asks driver route number/confirms
Hands payment to driver
Asks driver to call out desired stop
Requests transfer
Takes transfer from driver
Places transfer in secure holder
Sits in appropriate seat (to hear
driver)
Talks only to those in party
Pulls cord at appropriate stop OR
Stands when driver calls desired
stop
Stands when bus comes to stop
Exits bus to sidewalk
STAFF RATIO
DATE AND INITIAL
INDEPDNDENCE RATIO
Cooking and Kitchen Use Student name: IEP GOAL? Yes No
5= Exceptional, independently completed 2= Emerging, 2 or more direct cues given
4= Proficient, 1-2 indirect clues given 1= Poor, step-by-step directions given
3= Satisfactory, 1 direct cue given NA= Not Applicable
Gathers all necessary food items Comments (Date and Separate)
Washes hands
Finds kitchen tools as needed
Follows all recipe steps, in
sequence
Y or N: Completed in reasonable
time?
Sets table: plate, utensil, napkin
Sets cup on table
Pours drink
Scrapes any food off plate into
garbage
Puts dishes in sink
Throws away garbage
Washes dishes
Dries dishes
Puts dishes away
Wipes table
Picks up food off floor
Washes/wipes floor, if needed
Frustration Level 1(low) 5(high)
STAFF RATIO
DATE AND INITIAL
INDEPENDENCE RATIO
Kitchen tools or objects (circle if used)
Blender Can opener
Set oven/stove Toaster
Hot Pads/Mitts Knife for cutting
Cutting board Colander
Measure cups Measure spoons
DATE AND INITIAL
INDEPENDENCE RATIO
Eat-In Restaurant Student name: IEP GOAL? Yes No
5= Exceptional, independently completed 2= Emerging, 2 or more direct cues given
4= Proficient, 1-2 indirect clues given 1= Poor, step-by-step directions given
3= Satisfactory, 1 direct cue given NA= Not Applicable
Identifies desired food Comments (Date and Separate)
Identifies appropriate restaurant
Identifies transportation source
Tells staff time to go/leave
Walks to transportation
appropriately
Walks from van/cab to restaurant
Enters restaurant
Waits by wait sign to be seated
Greets wait staff appropriately
Walks with group to seat
Sits in appropriate seat
Opens and looks at menu
States food choice
States drink choice
Identifies if has enough $ for cost
Gives order when asked by waiter
Waits for food appropriately
Eats food appropriately
Looks at bill for cost
Takes out enough $ for bill
Pay for item at cashier or waiter
Used $ Over (Yes or No: Y N)
Gives $2 tip
Says thank you to waiter
Waits in area for rest of group
Exits restaurant with group
Asks for help as needed
STAFF RATIO
DATE AND INITIALS
INDEPENDENCE RATIO
Fast Food Restaurant Student name: IEP GOAL? Yes No
5= Exceptional, independently completed 2= Emerging, 2 or more direct cues given
4= Proficient, 1-2 indirect clues given 1= Poor, step-by-step directions given
3= Satisfactory, 1 direct cue given NA= Not Applicable
Identifies appropriate restaurant Comments (Date and Seperate)
Identifies desired items to order
Identifies enough money for order
Identifies transportation
Tells staff when to go
Walks to transportation
Walks from van/cab to restaurant
Enters restaurant
Walks to end of line
Stands in line appropriately
States desired item to cashier, when
asked
Pays for item when told price
Uses $ Over (Yes or No: Y N)
Waits for food
Steps to side if asked/indicated
Says thank you when given food
Takes food tray
Walks to appropriate table
Uses napkin when needed
Talks with empty mouth
Chews with closed mouth
Puts all trash on tray
Takes tray to trash
Places tray on holder
Waits for group
Exits restaurant with group
Asks for assistance, if needed
STAFF RATIO
DATE AND INITIALS
INDEPENDENCE RATIO
Shopping – General Student name: IEP GOAL? Yes No
5= Exceptional, independently completed 2= Emerging, 2 or more direct cues given
4= Proficient, 1-2 indirect clues given 1= Poor, step-by-step directions given
3= Satisfactory, 1 direct cue given NA= Not Applicable
Identifies store to shop at Comments (Date and Seperate)
Makes list of items needed
Estimates total $ needed
Places $ in wallet or purse
Walks from van/cab to store
Takes basket or cart if needed
Finds items according to list
Identifies fresh food/buy?
Identifies expiration date/buy?
Identifies brand/buy?
Identifies price/buy?
Gathers each item in possession
Walks to check out counter/cashier
Enters line, if needed
Stands appropriately in line
Places items on table, right time
Greets clerk
Pays for items when told price
Uses $ Over (Yes or No: Y N)
Waits for and takes change
Says “Thank you” to clerk
Takes items in bag
Exits store with group
Asks for help if needed
STAFF RATIO
DATE AND INITIAL
INDEPENDENCE RATIO
Grocery Store Student name: IEP GOAL? Yes No
5= Exceptional, independently completed 2= Emerging, 2 or more direct cues given
4= Proficient, 1-2 indirect clues given 1= Poor, step-by-step directions given
3= Satisfactory, 1 direct cue given NA= Not Applicable
Identifies items to purchase Comments (Date and Seperate)
Places items on list
Gets enough $ for purchase
Places $ in wallet or purse
Identifies when time to go
Walks with list to store/van
Enters store
Has grocery list out
Gets cart/basket if needed
Pushes cart
Finds items on list
Does not grab items not on list
Puts each item in cart
Walks to open check out lane
Stands in line, if needed
Unloads cart when turn
Answers plastic, if asked
Gets $ out while waiting
Pays for item when told price
Uses $ Over (Yes or No: Y N)
Takes change and receipt
Puts money away
Puts wallet in pocket/purse
Secures bag
Exits check out
Waits for group
Exits store with group
Asks for help if needed
STAFF RATIO
DATE AND INITIAL
INDEPENDENCE RATIO
Health Club Student name: IEP GOAL? Yes No
5= Exceptional, independently completed 2= Emerging, 2 or more direct cues given
4= Proficient, 1-2 indirect clues given 1= Poor, step-by-step directions given
3= Satisfactory, 1 direct cue given NA= Not Applicable
Walks to transportation on time Comments (Date and Seperate)
Walks from van/cab to HC
Enters HC
Greets attendant when checking in
Enters locker room
Finds correct locker
Unlocks and opens locker
Hangs up coat & fanny pack
Takes work out clothes from bag
Removes street clothes
Puts on work out clothes
Puts clothes and bag in locker
Closes and locks locker
Walks to exercise area
Starts exercise options
Treadmill
Bike
Rowing machine
Walk laps
Weight lifting
Completes exercise options
Walks to locker room when time
Unlocks and opens locker
Takes off work out clothes
Dresses in street clothes
Places work out clothes in bag
Closes locker and locks
Leaves health club
Asks for assistance as needed
STAFF RATIO
DATE AND INITIAL
INDEPENDENCE RATIO
Laundry Student name: IEP GOAL? Yes No
5= Exceptional, independently completed 2= Emerging, 2 or more direct cues given
4= Proficient, 1-2 indirect clues given 1= Poor, step-by-step directions given
3= Satisfactory, 1 direct cue given NA= Not Applicable
Identifies when time to go Comments (Date and Seperate)
Gathers laundry in basket
Gathers laundry supplies
Takes laundry to transportation
Takes laundry/supplies out of van
Walks to and enters Laundromat
Selects unused washing machine
Separates clothes by colors
Inserts correct detergent amount
Inserts correct coin amount
Adjusts washer settings as needed
Starts washer
Waits appropriately
Walks to washer when cycle ends
Removes clothes
Puts wet clothes in empty dryer
Closes dryer
Inserts correct coin amount in dryer
Sets dryer settings, if needed
Starts dryer
Waits appropriately
Walks to dryer when cycle ends
Removes clothes
Folds clothes as needed
Places folded clothes in basket
Repeats steps if has more laundry
Asks for help as needed
STAFF RATIO
DATE AND INITIAL
INDEPDENDENCE RATIO
Street Crossing Student name: IEP GOAL? Yes No
5= Exceptional, independently completed 2= Emerging, 2 or more direct cues given
4= Proficient, 1-2 indirect clues given 1= Poor, step-by-step directions given
3= Satisfactory, 1 direct cue given NA= Not Applicable
2-LANE, NO SIGN Comments (Date and Seperate)
Walks to corner
Stops at curb
Looks left and right for cars
Leaves curb after cars pass
Looks left and right while crossing
Walks in crosswalk
2-LANE, STOP SIGN
Walks to corner
Stops at curb
Looks left and right for cars
Leaves curb when all cars have
stopped
Looks left and right as crossing
street
Raises hand if car moves while
crossing
Walks in crosswalk
2 OR 4 LANE WITH
STOPLIGHT
Presses signal button
Walks to corner/crosswalk
Stops on curb
Looks at signal until changes
Starts crossing after signal change
Raises hand if car moves while
crossing
Keeps walking until reaches curb
STAFF RATIO
DATE AND INITIAL
INDEPENDENCE RATIO
University Course Attendance Student name: IEP GOAL? Yes No
5= Exceptional, independently completed 2= Emerging, 2 or more direct cues given
4= Proficient, 1-2 indirect clues given 1= Poor, step-by-step directions given
3= Satisfactory, 1 direct cue given NA= Not Applicable
Tells staff when its time to leave
Walks to van at right time
Walks from van/cab to class
Sits in appropriate seat
Says hello to peers
Attends to lesson
Quiet while teacher talks
Looks at teacher during lecture
Writes notes, if needed
Maintains appropriate behavior
Participates/Answers questions
Says goodbye to peers
Leaves class when time
Walks from class to van/cab
STAFF RATIO
DATE AND INITIAL
INDEPENDENCE RATIO
Vocational Student name: IEP GOAL? Yes No
5= Exceptional, independently completed 2= Emerging, 2 or more direct cues given
4= Proficient, 1-2 indirect clues given 1= Poor, step-by-step directions given
3= Satisfactory, 1 direct cue given NA= Not Applicable
Changes into uniform, if needed Comments (Date and Seperate)
Checks self in mirror w/ checklist
Looks for cab until it arrives
Walks to cab
Arrives in appropriate dress
Properly groomed for work
Walks from cab to workplace
Enters workplace
Greets coworkers
Gathers needed materials
Starts work routine
# of tasks in routine
# of tasks completed
# Additional tasks completed
Changes tasks appropriately
Stops work at break time
Walks to break area
Is appropriate during break
Leaves break on time
Returns to work area/task
Requests break as needed
Identifies time when to stop work
Returns work materials when done
Walks and waits for transportation
STAFF RATIO
DATE AND INITIAL
INDEPENDENCE RATIO
Longest period worked without
cues or help
Transportation Student name: IEP GOAL? Yes No
5= Exceptional, independently completed 2= Emerging, 2 or more direct cues given
4= Proficient, 1-2 indirect clues given 1= Poor, step-by-step directions given
3= Satisfactory, 1 direct cue given NA= Not Applicable
VAN/CAB Comments (Date and Seperate)
Opens door
Gets in seat correctly
Closes door, if needed
Pulls seat belt across chest and
waist
Clicks belt in place
Waits until fully stopped before
starts to remove seat belt
Removes seat belt
Opens door and exits van
WALKING
Walks on sidewalk with group
Remains with group (10’ close)
Stops when group stops
STAFF RATIO
DATE AND INITIALS
INDEPENDENCE RATIO
ATM Withdrawal Student name: IEP GOAL? Yes No
5= Exceptional, independently completed 2= Emerging, 2 or more direct cues given
4= Proficient, 1-2 indirect clues given 1= Poor, step-by-step directions given
3= Satisfactory, 1 direct cue given NA= Not Applicable
Moves from street corner to bank Comments (Date and Seperate)
Enters bank door
Enters line if needed
remains 5’ behind person using ATM
walks to ATM when turn
Gets card out
inserts card in slot
rotates and reinserts card correctly if
inserted incorrectly 1st time.
waits until screen prompts
correctly types in PIN #
selects correct account
inputs correct withdrawal amount
presses “enter” to confirm
presses “cancel” if typed incorrectly
takes money
answers “no” to additional exchanges
waits for card and takes when ejected
places card in wallet
takes receipt from machine
places receipt in wallet
places wallet in pocket or purse
gets 20 $1 bills
STAFF RATIO
DATE AND INITIAL
INDEPENDENCE RATIO
Check Deposit Student name: IEP GOAL? Yes No
5= Exceptional, independently completed 2= Emerging, 2 or more direct cues given
4= Proficient, 1-2 indirect clues given 1= Poor, step-by-step directions given
3= Satisfactory, 1 direct cue given NA= Not Applicable
gathers necessary deposit papers Comments (Date and Seperate)
removes card with account info.
writes deposit amount on slip
writes account info on slip
signs back of check
enters bank door
enters line for cashier
walks up to cashier
asks to deposit check
waits for deposit receipt
takes receipt
says thank you
exits line
leaves bank with group
STAFF RATIO
DATE AND INITIAL
INDEPENDENCE RATIO
Additional Comments (Date and Seperate)
WALKING CLUB Student name: IEP GOAL? Yes No
5= Exceptional, independently completed 2= Emerging, 2 or more direct cues given
4= Proficient, 1-2 indirect clues given 1= Poor, step-by-step directions given
3= Satisfactory, 1 direct cue given NA= Not Applicable
Chooses where to walk Comments (Date)
Changes shoes if necessary
Changes shirt is necessary
Walks to transportation
Wears seatbelt correctly
Gets out of van
Walks to site
Starts walking
Walks for designated amt. of time
Stays in area
Stops at designated time
Gets in van
Wears seatbelt correctly
Gets out of van
Changes shoes if necessary
Changes shirt if necessary
Completes Prep
Completes Review
STAFF RATIO
DATE AND INITIAL
INDEPENDENCE RATIO