SWEP 2018 (Summer Work Experience Program)

SWEP 2018 (Summer Work Experience Program) YTP/VRC REFFERAL FORM **** Please Attach Student Resume Electronically If Available and recent Photo****

Student Name: SSID: Student’s Birthdate:

Student’s Address: Student’s Phone Number:

Student’s Email: Parent’s Names: Parent’s Phone Number:

YTP Specialist: Phone: Email:

VRC: Phone: Email:

Year in School: School of Reference:

Diagnosis (List All): Functional Limitations: (please check all that apply and explain)

Interpersonal Skills: Difficulty recognizing social cues? (i.e. facial expression, body language, tone of voice, personal space) Difficulty handling constructive criticism Difficulty managing frustration (i.e. overreacts, withdrawals) Lacks appropriate social skills or uncomfortable in social situations Difficulty effectively resolving conflict or problem solving Difficulty working in groups

Communication: Unable to communicate verbally Speech and verbal language is difficult to understand Unable to effectively communicate via telephone, email and/or text Difficulty initiating or sustain conversation Conversation may be limited to single words, short phrases or illogical rambling Talks and interrupts excessively Difficulty following written instructions or interpret written materials Difficulty communicating needs effectively Difficulty understanding instructions and expectations Difficulties generalizing, transferring, and/or assimilating information Illegible handwriting Unable to describe skills, work, and education (i.e. application/employment interview) Work Tolerance: Difficulty completing a full day of school Poor Attendance Has low level of capacity or endurance due to physical or mental limitations Difficulties managing stressful environments Needs frequent breaks or modified schedule Inability to remain in one physical location for extended time period without fidgeting, feeling restless, or fleeing the site Difficulties ignoring normal background noise that prevents focus on the task Difficulties establishing and/or maintaining relationships with peers and/or staff

Work Skills: Difficulty maintain attention to a task for a reasonable amount of time Difficulty remembering directions or needs information repeated frequently Significant impairments in academic skills Frequently tardy Difficulty learning new tasks Difficulty taking initiative without prompts Needs frequent reminders to stay on tasks to completion Impaired ability to refocus after interruption Difficulties conforming to establish rules or norms Impaired ability to remain aware of and adhere to safety guidelines Impaired ability to generalize learning from on job task to another

Self-Direction: Impaired ability to follow directions Impaired ability to complete tasks and work independently in a timely manner Lacks self-advocacy skills Inability to use feedback to improve or correct work performance Inability to sustain effort and stay focused especially when confronted with a problem or change Impaired ability to understand and change behavior as a result of consequences Difficulties shifting from one activity to another Cognitive deficits impairing work quality or productivity Inability to make decisions independent of others

Self Care: Difficulty performing daily living activities independently (i.e. hygiene, feeding, toileting, safety, health) Difficulty adjusting to change in routine (i.e. transitioning from one activity to another) Poor decision making or unaware of consequences of behavior Requires support and/or personal care attendant personnel Difficulties in math and reading that impacts management of finances, transportation and health care Impaired ability to apply past experiences and learning decision making Needs adaptations to their environment to be independent Vulnerable or susceptible to being taken advantage of/ can’t recognize threats/potential danger Environmental Conditions: Difficulty with extreme conditions (cold or hot) Difficulty with working outside Difficulty working indoors

Mobility/Motor Skills: Difficulty with gross motor skills Difficulty with fine motor skills Moves slower than average and fatigues easily Difficulty performing tasks at a competitive pace Difficulty using public transportation Requires assistance getting around the community Difficulty reading street signs or bus schedules Difficulty recalling basic location directions Difficulty traveling due to social, emotional and/or physical challenge Difficulty managing time independently Limitations in understanding directions, organization, sequencing and or planning

Accommodations/Assistive Technology Devices: (please list any accommodation needs known and any assistive technology devices used, proficiency with devices 1=minimal 5=outstanding and if they are allowed to use them over the summer.):

Travel Training (experience is not required): Student can accurately and independently gather travel information? Yes No Unsure Can the student travel on public transportation independently? Yes No Unsure Describe the student’s community travel skills (include intersections-stop signs, lighted intersections, street crossing, etc.):

Computer Skills: Please list all devices student has knowledge of using. Please rate proficiency on a scale of 1-5, 1=minimal competency, 5= outstanding competency 1 2 3 4 5  Use of internet  Use of email  Word Processing  Excel  Powerpoint  Keyboarding  Other: Please List:

Students Top Three Strengths: 1. 2. 3. Student’s Job Interest Areas: (In Order of Interest): 1. 2. 3.

Student’s Skill Interest Areas: Below are tasks that the student may be asked to do during their summer work experience. Please check ALL tasks they may be interested in: Speaking/interacting with customers Caring for animals (Ex: doggie daycare) Caring for children/infants Receiving/processing money/customer payments Providing information to customers Working in the great outdoors Stocking/moving items Preparing/serving hot or cold beverages Working with hands/physical labor Computer work/office administration Teaching/Mentoring others Design, art, engineering or the desire to create Landscaping tasks Presenting in front of a group Preparing/serving food/snacks Cleaning/organizing Other: ______

Volunteer and Work Experience *** Please attach an electronic copy of the resume*** Has the student had any in-school work experiences? Any volunteer or paid work in the community? If so, please list tasks preformed: How many hours do you feel the student can work per day (work tolerance): How many hours do you feel the student can independently work per day (w/out job coach): Daily Living Skills: Independent Needs Cues or Not at all Not Known Assistance Sweeping Mopping Wiping Surfaces Vacuuming Emptying trashcans Washing Dishes Operates Machine Does laundry Cook more than a 3 ingredient recipe Operate microwave Operate Range/Oven Cleanup of materials Cleanup of used surfaces Tooth brushing Hair Care Hygiene needs Has ability to budget money

What goals do you hope for this student if they are accepted into SWEP? 1. 2. 3.

Other Information you would like us to know: