Community Based Work Assessment Tool s1

Transition Educational Exiting Profile

I. Name Jonathon Boyer D.O.B 7-14-86

Student Address Child First, 1655 Valley Center Parkway, Suite 150, Bethlehm, PA 18017 SS#

Parent/Guardian Brooke Horst, BS (Child First) (Berks County Children & Youth, Richard Grant) Phone # xxx-xxx-xxxx Ext. xxx

Diagnosed Primary Disability Emotional Disturbance Secondary Disability (mild) Mental Retardation

Medication(s) Abilify (anxiety)

County Currently - Berks Co. EDUCATIONAL INFORMATION

II. High School Graduate Yes No Date of Graduation December 2007

Name of School Palmerton Alternative Education Teacher Amy Buss

Type of Program Emotional Support Home District Jim Thorpe

Reading Level Fourth Grade Math Level Fourth Grade ELIGIBILITY INFORMATION III. Does the individual receive SSI Benefits? Yes No Does the individual receive SSDI benefits? Yes No Has the family/individual received information on Social Security Work Incentives and/or MAWD? Yes No (i.e. PASS, Ticket-to-Work, Impairment Related Work Expense) Has the individual met with a Work Incentive Planning Assistance Program (WIPA)? Yes No Does the individual have a Social Security identification card? Yes No Does the individual have a Pennsylvania Photo Identification Card? Yes No Is the individual registered to vote? Yes No Does the individual have a Driver’s License? Yes No Is it a realistic goal for the individual to get a Driver’s License? Yes No Does the individual have an ACCESS card? Yes No #

This document is the result of a collaborative effort of CLIU 21, CIU 20, DCIU 25, Private Industry Council, VIA of the Lehigh Valley, OVR, OMR of Lehigh County and Delaware County – OPTIONS Job Developer No parts of this document are to be used or reproduced without permission from Lehigh Valley & Northampton Employment Project What type of medical insurance does the individual have? When does this medical insurance benefit end? Is the individual eligible for services through the MR system? Yes No If yes, Name of Supports Coordinator for MR system: currently getting information transferred to Carbon County Is the individual eligible for services through the MH system? Yes No If yes, Name of Case Manager for MH system: currently getting information transferred to Carbon County Is the individual eligible for OVR services? Yes No If yes, date application was completed. (2 years prior to graduation) Does the individual currently receive OVR services? Yes No Name of OVR Counselor:

If the individual receives other services, please list agencies, providers, and contact person(s): C & Y in Berks County 610-XXX-XXXX (Richard Grant), Butch Decker (Berks Co. MH/MR - 610-XXX-XXXX

IV. Participants who contributed to completing this Profile

Name Amy Buss Role Teacher Phone Number 610-xxx-xxxx Areas completed I, II, III, IV, V, VI

Name Jonathon Boyer Role Student Phone Number 570-XXX-XXXX Areas completed I, II, III, IV, V, VI

Name Sam Rover Role Work Exp. Coord. Phone Number 610-769-XXXX Areas completed I, II, III, IV, V, VI

Name Betty Benjamin Role Transition Consultant Phone Number 610-769-XXXX Areas completed I, II, III, IV, V, VI

Name Role Phone Number Areas completed

Summer Contact Number, Extension and Name for additional documents and further information: Records Department @ CLIU #21, 610-XXX- XXXX

This document is the result of a collaborative effort of CLIU 21, CIU 20, DCIU 25, Private Industry Council, VIA of the Lehigh Valley, OVR, OMR of Lehigh County and Delaware County – OPTIONS Job Developer No parts of this document are to be used or reproduced without permission from Lehigh Valley & Northampton Employment Project v. ESSENTIAL INFORMATION: Complete by checking, adding comments or writing “Not Applicable”

A. Individual Desires to be Competitively Employed in the Community: YES NO (Check) Full-time employment Part-time employment Less than 20 hours per week

Scheduling Concerns: (church activities, recreation/leisure activities, lack of experience with fulltime employment): Transportation

Negotiable/Nonnegotiable: (activities that could conflict with structured competitive employment schedule): (List)

B. Communication: 1. Mode of communication: (Check what applies) a. Verbal If yes, describe type of communication (e.g. one word, utterances, complete sentences). Speaks in complete sentences b. Non-verbal If yes, describe type of communication (i.e. communication board, picture book, eye gaze, is an interpreter needed).

2. Primary Language: English

C. Family Supports available to assist individual in meeting this post-school outcome: Parent Guardian Sibling Friend Other (Identify)

Parent Sibling Other Guardian Berks County Children & Youth, Richard Friend Grant until age 21, Dec. 2007

This document is the result of a collaborative effort of CLIU 21, CIU 20, DCIU 25, Private Industry Council, VIA of the Lehigh Valley, OVR, OMR of Lehigh County and Delaware County – OPTIONS Job Developer No parts of this document are to be used or reproduced without permission from Lehigh Valley & Northampton Employment Project D. Transportation: 1. Mode of Transportation to and from work: (Check all that apply) a. Public: Bus Cab Specialized Transportation b. Driver’s License/car Family Friends Walk Other

2. Type of support needed: (Check what applies) a. Independent b. Needs Training (i.e. Training in Pedestrian Safety, Training in reading & interpreting a bus schedule-Travel Instruction) c. Needs Assistance (to access transportation services) d. Travel Instruction Assessment Completed e. Evaluator’s Name

E. Individual’s job preferences/expressed areas of interest: (List) Recommendations by IEP Team: Jonathon likes working with children (can relate to similar experiences based The team recommends that Jonathon receive additional job training. on his own personal experiences)

F. Employment Possibilities Near Residence or through Personal Contacts: (List business name and address if known) Due to a possible change in county services and relocation, a recommendation can not be made.

G. Work-Based Learning: (Check)

Career Days Internship Work Release (paid) Career Expos Job Shadowing Work Study Cooperative Education Registered Apprenticeship Volunteering Community-Based Vocational Training Service Learning Other Diversified Occupation Program Work Experience (part-time/full-time)

(List) CBVT - CLIU Resource Library, SS Palmer Library, Pyramid (restaurant), Dollar Tree, Other: Paid employment at Spilt Rock Lodge (completed application and had an interview) G. Work-Based Learning: (continued) No work related experiences: (Explain)

This document is the result of a collaborative effort of CLIU 21, CIU 20, DCIU 25, Private Industry Council, VIA of the Lehigh Valley, OVR, OMR of Lehigh County and Delaware County – OPTIONS Job Developer No parts of this document are to be used or reproduced without permission from Lehigh Valley & Northampton Employment Project H. Specific Job Tasks: (Check) Able to perform: One step task Two/three step tasks Multi-step tasks (Describe tasks and level of independence) Split Rock Lodge: housekeeping chores, translation of Spanish to English, CLIU Resource Library/SS Palmer Library: categorize materials, scan and return materials to assigned shelves, Dollar Tree: customer service, stocking shelves, separating bulk items, Pyramid Restaurant: stock refrigerator, basic food preparation, cleaning kitchen area Does the individual meet employer expectations? (Comments) Comparison of student to program expectations - yes, however, work history (Split Rock) may indicate initial job training and follow along to maintain competetive employment.

I. Description of Strengths and Abilities in Jobs Assessed: (Describe) Able to communicate his basic wants and needs, able to perform the necessary tasks and duties at current work related sites, has clear ideas of what types of jobs he likes to perform, endurance, positive attitude and cooperative effort, takes pride in his work

J. Motor/Mobility Skills: (Check) – Independent Wheelchair Crutches Cane Walker Assistance Needed (Describe)

K. Endurance: (Check) 1. Endurance is less than: 1 hour 1-2 hours 2-3 hours or more 3 hours or more 2. Can the individual work while seated for at least 2 hours at a time? Yes No Don’t Know 3. Can the individual work while standing for at least 2 hours at a time? Yes No Don’t Know 4. Must the individual alternate between standing and sitting? Yes No 5. Individual can: Lift pounds, Carry pounds, Push pounds 6. List any restrictions: sit stand kneel stoop bend crawl

Comments: Josue can lift/carry and/or push a minimum of 40 lbs.

L. Individual’s Behavior in Work Environment and Supports Needed to Maintain Appropriate Behavior: (List) It is essential for Jonathon to have a contact person to share his concerns and expectations. Jonathon can overact to peer interaction, but can be redirected with removal of situation and an opportunity to quietly share what occurred.

M. Accommodations/Environmental/Sensory Considerations Needing to be Addressed: (List) Jonathon is independent at work sites, but needs intermittent supervison to verify success of tasks. Josue needs specific and clear cut verbal directions for work completion. Any written print form would require extended time or further assistance in completing.

This document is the result of a collaborative effort of CLIU 21, CIU 20, DCIU 25, Private Industry Council, VIA of the Lehigh Valley, OVR, OMR of Lehigh County and Delaware County – OPTIONS Job Developer No parts of this document are to be used or reproduced without permission from Lehigh Valley & Northampton Employment Project N. Habits, Routines, Idiosyncrasies: (List) Jonathon can obsess over social situations, however he can be redirected through verbal prompts and ignorning his comments.

O. Safety Considerations: (i.e. Overly friendly, unaware of danger/environment, knowing what to do in an emergency, carries ID, has emergency contact list) (List) Jonathon is able to respond in basic emergency situations.

P. OTHER COMMMENTS If Jonathon lives in Carbon County, the PwD (People with Disabilities) transportation is an option for employment, recreation and leisure. The bus is a possiblity if available. Jonathon performs well when appearance is professional and the environment is established as business like. He learns best by following a model and then with verbal directions as needed. Jonathon clearly distinquishes between adult and student settings. He interacts more positively in a work situation with adult peers. In a classroom environment, he can be distracted and can inappropriately interact with teen peers especially when he feels as if it is personalized.Jonathon still demonstrates immuaturity (verbalization- younger peers) in peer relationships.

This document is the result of a collaborative effort of CLIU 21, CIU 20, DCIU 25, Private Industry Council, VIA of the Lehigh Valley, OVR, OMR of Lehigh County and Delaware County – OPTIONS Job Developer No parts of this document are to be used or reproduced without permission from Lehigh Valley & Northampton Employment Project VI. Mark by indicating: 3-Independent/strong ability, 2-Support Needed, 1-Not evident A. Communication Response Code 3 2 1 COMMENTS Expresses basic needs and wants Asks for assistance Speaks effectively Understands verbal instructions Follows verbal instructions Understands written instructions Follows written instructions Interprets non-verbal cues and gestures Requests accommodations Reports work related problems to supervisor/coworker Able to answer telephone appropriately Takes an accurate telephone message Detailed messages would be difficult Leaves an appropriate telephone message Asks for time off appropriately Completes paper application with varying prompts, reading level concerns Able to complete alternate format applications (online, phone, electronics, NA etc.) Provides current medication information Utilizes cell phone

This document is the result of a collaborative effort of CLIU 21, CIU 20, DCIU 25, Private Industry Council, VIA of the Lehigh Valley, OVR, OMR of Lehigh County and Delaware County – OPTIONS Job Developer No parts of this document are to be used or reproduced without permission from Lehigh Valley & Northampton Employment Project Mark by indicating: 3-Independent/strong ability, 2-Support Needed, 1-Not evident B. Planning and Problem solving Response Code 3 2 1 COMMENTS In the classroom, when threatens can retaliate; on the job Exhibits decision making skills site - appropriate Adapts to change Down time is very difficult Takes initiative Understands employer expectations Follows emergency procedures Exhibits perseverance Respects adult opinion, but has difficulty with peer Respects opinions/customs/differences of others disagreements When Jonathon is calm, he is able to accept the Accepts constructive feedback (criticism) constructive feedback. Accepts compliments Handles physical problems that arise (i.e. illness, pain or bodily function) Shares frequently in this area. Takes necessary medications according to instructions NA Recognizes/reports unsafe condition(s) C. SOCIAL INTERACTION Response Code 3 2 1 COMMENTS Establishes rapport with others Relates much better with adults than peers. Brings only work-related items to work Keeps personal issues separate from work Jonathon needs guidance as to what is appropriate. Interacts appropriately with coworkers/supervisor during break time Interacts appropriately with coworkers/supervisor during work activity Respects personal space of others Respects personal property of others Exhibits firm handshake Exhibits eye contact Answers general interview questions appropriately Demonstrates appropriate table manners/eating habits during break

This document is the result of a collaborative effort of CLIU 21, CIU 20, DCIU 25, Private Industry Council, VIA of the Lehigh Valley, OVR, OMR of Lehigh County and Delaware County – OPTIONS Job Developer No parts of this document are to be used or reproduced without permission from Lehigh Valley & Northampton Employment Project Mark by indicating: 3-Independent/strong ability, 2-Support Needed. 1-Not evident C. SOCIAL INTERACTION (continued) Response Code 3 2 1 COMMENTS Listens while others are speaking Engages in conversation Situational based on professional vs. peers. Dresses/grooms appropriately Offers help D. Work skills Response Code 3 2 1 COMMENTS Understands work responsibilities Remains focused Locates tools/equipment Returns tools/equipment to proper place Works under pressure/meets deadlines/makes rate Recognizes obligation to attend trainings or other work related meetings NA Completes assigned task(s) E. Punctuality Response Code 3 2 1 COMMENTS Arrives to work on time Leaves and returns from break on time Leaves and returns from lunch on time Attends work as schedule Clocks in/out of work accurately Tells time standard/digital Uses a clock or watch to manage time Keeps and manages own schedule Strategies given for organization (listed on SOP) Date of Transition Educational Exiting Profile Finalized 4/17/07 Student Signature ______

Staff Member Signature ______

“CLIU is a student-centered education agency committed to Excellence through Service.”

This document is the result of a collaborative effort of CLIU 21, CIU 20, DCIU 25, Private Industry Council, VIA of the Lehigh Valley, OVR, OMR of Lehigh County and Delaware County – OPTIONS Job Developer No parts of this document are to be used or reproduced without permission from Lehigh Valley & Northampton Employment Project The Carbon Lehigh Intermediate Unit is an equal opportunity employer and does not discriminate on the basis of race, color, religion, national origin, age, marital status, sex or non-relevant handicap in activities, programs, or employment practices. For information regarding civil rights or grievance procedures contact Mr. John B. Houser, Section 504 Coordinator or Mrs. Kim Talipan, Title IX and ADA Coordinator at the Carbon Lehigh Intermediate Unit, 4210 Independence Drive, Schnecksville, PA 18078-2580, 800-223-4821.

This document is the result of a collaborative effort of CLIU 21, CIU 20, DCIU 25, Private Industry Council, VIA of the Lehigh Valley, OVR, OMR of Lehigh County and Delaware County – OPTIONS Job Developer No parts of this document are to be used or reproduced without permission from Lehigh Valley & Northampton Employment Project