TOOLKIT

Form 1: The Personal Profile..................................................................................2Form 2: The Service Plan.......................................................................................5Form 3: The Progress Form....................................................................................7Form 4- Community Assessment Form..................................................................8Form 5- Potential Employer Form........................................................................11Form 6- The Job Analysis Form A.........................................................................13Form 7- The Job Analysis Form B.........................................................................14Form 8- The Baseline Assessment.......................................................................15Form 9 -The Task Training Form..........................................................................16Form 10-Employer Feedback Form......................................................................17Form 11- Employer’s Evaluation Form B..............................................................18Form 12- Employee Evaluation Form...................................................................19

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Form 1: The Personal Profile

IDENTIFICATIONName: ________________________________ Address: _____________________________

Province: SK Postal Code: ___________Telephone: ___________________________

Agency Name and Location______________________ Date of Birth:______________________

SIN___________________

What kind of work have you done? Where did you learn how to do the things you do?

1. __________________________________________________________________________

2. __________________________________________________________________________

3. __________________________________________________________________________

4. __________________________________________________________________________

___________________________________________________________________________

How do you get around ?

Drives own car Can take a bus Someone is available to drive

Walks Transportation will have to be arranged. Rides a bike

Medical

Do you have any medical problems that might interfere with working everyday? For example, do you have to have pills or shots given to you? Do you have seizures that aren't controlled by medication? _____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Who should we notify in case of emergency? _______________________________________

Emergency Instructions: ________________________________________________________

____________________________________________________________________________

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____________________________________________________________________________

Income

1.Are you on Social Assistance? ___ Yes ___No

2. Sometimes, getting a job can change how much social assistance you get. If you get a job, we may want to speak to your worker. Is this okay with you? ___ Yes ___No3. Do you know the name of your worker? ___ Yes ___No

Support InformationSometimes, people like to have other people they know come to meetings to help them find work. Sometimes, people choose family, sometimes they choose friends, and sometimes they choose people they already work with. All these people are fine to have at a meeting. Who would you like to have at a meeting with you?

1. Name of Support Person_______________________________________________

Contact Information__________________________________________________

2. Name of Support Person_______________________________________________

Contact Information__________________________________________________

3. Name of Support Person_______________________________________________

Contact Information__________________________________________________

Interests

What do you like doing?_________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

What do you hate doing? ________________________________________________

_____________________________________________________________________________

What do you do everyday? Do you have a routine that you like to follow?

_____________________________________________________________________________

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Do you have any hobbies? _____________________________________________________________________________

What is your idea of a perfect job?

Are you looking for __Part Time, __Casual, __Seasonal, __Full-Time

Things to Work On

Sometimes, people want to work in the community but have problems getting jobs, or keeping jobs. That's okay, lots of us do have problems sometimes. Sometimes we have problems getting to work, or learning new things, sometimes, we don't have a lot of experience, or we don't know how to start. Some of us cannot read, and some of us cannot drive. We want to know what you think could be a problem, so that we can work on it together.

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Profile Documented by: ____________________________________ (Name of Service Provider)

Signature of Employee Candidate or Guardian: ____________________________________

Date of Completion: _______________________

Form 2: The Service Plan

Service Plan-Form

Name____________________________________________________________________

Address___________________________________________________________________

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Phone No___________________________________________________________________

Career development practitioner__________________________________________________________________

Career development practitioner Phone No__________________________________________________________

What three things should we work on first?

1. _________________________________________________________________________

2. _________________________________________________________________________

3. _________________________________________________________________________

Who will do what thing?

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

What things do we have to help us? Who do we know? _____________________________________________________________________________

_____________________________________________________________________________

Are there things we need? People we have to call for help? _____________________________________________________________________________

____________________________________________________________________________

When should we meet again? ____________________________________________________

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Form 3: The Progress Form

Progress Form______________________________________________________

Agency___________________________

Participant Name: _____________________

Service Provider: ______________________ Date:_________

***************************************************************************************************************Goal __________________________________________________________. Progress to date: ______________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

Any additional supports required: ______________________________________________________________

______________________________________________________________

Date for Review__________________________

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Form 4- Community Assessment Form

Name of Community________________________________________________

Population_____________________

Nearest City____________________________________________________

Main Industries___________________________________________________

Contact Information

Town or City Office

Contact Person_________________________ Telephone # ______________ Mailing Address___________________________________________________

Website Address__________________________________________________

Fax # ______________________Email_______________________________

Media

Name of Business__________________________________________________

Contact Person__________________________Position____________________

Mailing Address___________________________________________________

Website Address__________________________________________________

Email___________________________________________________________

Telephone #_______________________ Fax__________________________

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Contact InformationMLA

Contact Person_________________________ Telephone # _______________________ Mailing Address______________________________________________________________

Website Address_____________________________________________________________

Fax # ________________________________ Email_______________________________

Chamber of Commerce Members or Town Officials

1. Name_________________________________ Telephone #________________________

Position__________________________________

2. Name_________________________________ Telephone #________________________

Position__________________________________

3. Name_________________________________ Telephone #________________________

Position__________________________________

Public Service Utilities (ie. Hospitals, police stations etc, crown corporations, schools, tourism etc.

Name of Utility________________________________________________________

Contact Person_________________________Telephone #_______________________

Functions___________________________________________________________________

Name of Utility________________________________________________________

Contact Person_________________________Telephone #_______________________

Functions___________________________________________________________________

Name of Utility________________________________________________________

Contact Person_________________________Telephone #_______________________

Functions___________________________________________________________________

Organizations, Associations, Groups and other Health Organizations (for

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example Food bank, Alcoholics Anonymous etc.

Name of Organization_____________________________________________________

Contact Person_________________________Telephone #_______________________

Functions___________________________________________________________________

Name of Organization_____________________________________________________

Contact Person_______________________Telephone #_________________________

Functions______________________________________________________________

Name of Organization_____________________________________________________

Contact Person_______________________Telephone #_________________________

Functions______________________________________________________________

Main Employers

Name of Business________________________________________________________

Contact Person_____________________Telephone #___________________________

Primary Function_________________________________________________________

Name of Business____________________________________________________________

Contact Person_______________________Telephone #_________________________

Primary Function________________________________________________________

Name of Business________________________________________________________

Contact Person_______________________Telephone #_________________________

Primary Function________________________________________________________

Form 5- Potential Employer Form

POTENTIAL EMPLOYER FORM

Potential Employer(s) for

Name (Person who is job seeking):__________________________________________

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Date:_______________________________________________________________

Name of Agency:_______________________________________________________

Name of Career development practitioner:____________________________________*********************************************************************************

1. Name of Business_____________________________________________________

Contact Person_______________________ Telephone #______________________

Website Address_______________________________________________________ Email________________________________________________________________

What kind of business is this?____________________________________________

Why is this job a good match?

_____________________________________________________________________ ____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________

What does the employer do when they want to hire someone?__Word of mouth __Newspaper ad __Ask someone they know

Comments

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Form 6- The Job Analysis Form A

Job Analysis Form A

Name of Company_______________________________________________________

Address______________________________________________________________

Date_____________________________ Telephone__________________________

Employer_________________________ Direct Supervisor_____________________

Name of Position______________________ Benefits___________________________

Work Schedule_________________________________________________________

Review Period____________________________Rate of Pay______________________

Names of Co-Workers____________________________________________________

Work Site Layout_______________________________________________________

General Duties (A job description is preferred.)_________________________________________________________________________________________________________________________________________________________________________

Machinery/Equipment to Be Operated:________________________________________________________________________________________________________________________________________

Chemicals Required:__________________________________________________________________________________________________________________________

Physical Observations:

___Clean work area ___Safe Environment ____Barrier Free ___Ramps, Curb Cuts

Comments_____________________________________________________________

Signature of Career development practitioner _______________________Date_____________________Form 7- The Job Analysis Form B

COMPANY________________________________Telephone_____________________

Address_____________________________ Contact Person______________________

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Telephone____________________ Employee Name______________________

Job Title_____________________________________________________________

Core Work Routines Episodic Work Routines1. ______________________________ 1._______________________________

2. ______________________________ 2._______________________________

3. ______________________________ 3._______________________________

4. ______________________________ 4._______________________________

Job Related Routines Accommodations Required

1. ______________________________ 1.________________________________

2. ______________________________ 2._______________________________

3. ______________________________ 3._______________________________

4. ______________________________ 4._______________________________

Job Summary:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

This section is intended to make notes about other job-related items, such as availability of coworkers, culture of the workplace etc. Anything else that the career development practitioner thinks is important.

Career development practitioner Signature_______________________________ Date________________

Form 8- The Baseline Assessment

Employment Site: ___________________________________________________________

Job Title: __________________________________________________________________

Duty: _____________________________________________________________________

Materials/Tools Required: ____________________________________________________

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Career development practitioner__________________________________Date___________________________

Task Step I VP RM PG PS Actual step in the task where error occurred.

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

Total # of independent tasks.

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Form 9 -The Task Training Form

I= IndependentVP =Verbal PromptD = DemonstrationP = Physical GuidanceRM= Role Modeling

TASK Training Form

Worker:______________________________ Job Site:______________________

Career development practitioner:__________________________Date:_________________________

Task

Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7

Picks up the doorI

Gets the handle vp

Lines up the handle in the correct spot

rm

Picks up the drill vp

Secures the handle i

Total # of steps

Total # of independent trials _2___ ____ _____ _____ _____ _____ _____

Summary: ___________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

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Form 10-Employer Feedback Form

Feedback Form for Employer: _______________________________________________

Duty _______________________________________________________________1 2 3 4 5 6 7 8 9 10Not Satisfied Somewhat Satisfied Excellent

Comments:____________________________________________________________

____________________________________________________________________

Duty .______________________________________________________________1 2 3 4 5 6 7 8 9 10Not Satisfied Somewhat Satisfied Excellent

Comments:____________________________________________________________

____________________________________________________________________

Duty ._______________________________________________________________1 2 3 4 5 6 7 8 9 10Not Satisfied Somewhat Satisfied Excellent

Comments:____________________________________________________________

____________________________________________________________________

Corrective Measures:____________________________________________________

____________________________________________________________________

____________________________________________________________________

Employer Signature_______________________

Employee Signature_______________________

Career development practitioner Signature______________________

Date__________________________Follow up date___________________________Form 11- Employer’s Evaluation Form B

Employer Name_______________________ Company_________________________

Supervisor__________________________ Employee Name___________________

Employer Telephone Number_________________________ Date__________________

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1. Do you feel you can call us if you have a problem? Yes No

Comments:___________________________________________________________

2. Do we respond to your requirements quickly and effectively? Yes No

Comments:____________________________________________________________

4. Do you feel the employee you hired was properly prepared for starting the job? Yes NoComments:____________________________________________________________

4. After initial training, do employee(s) meet your expectations? Yes No

Comments:____________________________________________________________

5. Have you needed to use our supported employment person to resolve work issues after the initial training? Yes No

Comments:___________________________________________________________

6. Overall do employee(s) meet your expectations? Yes No

Comments:____________________________________________________________

7. Overall do the services provided by the supported employment program meet your expectations? Yes No

Comments:____________________________________________________________

8. Would you use our services again? Yes No

Comments:____________________________________________________________

Form 12- Employee Evaluation Form

Employee Name:_________________________ Signature______________________

Agency_________________________ Date______________________________

Career development practitioner -(Support Person) __________________

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1. Are the staff at this agency, especially your support person, friendly and helpful ? Yes No

Comments:____________________________________________________________

____________________________________________________________________

5. Have you been able to find a job with the help of your support person? Yes No

Comments:____________________________________________________________

____________________________________________________________________

6. Did you feel you were prepared for the job? Yes No

Comments:____________________________________________________________

____________________________________________________________________

4.When you first started the job did the support person provide training and support? Yes No

Comments:____________________________________________________________

____________________________________________________________________

5. Please check off all the parts of the job that you are satisfied with.Job Title Yes No Comments:___________________________________________________________

Duties Yes No Comments:___________________________________________________________

Hours Yes No Comments:___________________________________________________________

Pay Yes No

Comments:___________________________________________________________

Location Yes No Comments:___________________________________________________________

Coworker Relationships Yes No Comments:___________________________________________________________

Supervisor Relationships Yes No

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Comments:___________________________________________________________

1. How often does your support person keep in touch with you?______________________________________________________________

7. Have you had a problem on the job that the support person has helped you solve? Yes No

Comments:____________________________________________________________

8. If you had a problem at the job, would you ask your support person for help? Yes NoComments:____________________________________________________________

9. Would you ask your support person to help you find another job if you needed help in the future? Yes No

10. Is there anything else you want to say?

I am signing to say that I have had this evaluation explained to me.

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