Bathroom Skills/Toilet Use - Structure...Bathroom Skills/Toilet Use Student name: IEP GOAL? Yes No 5= Exceptional, independently completed 2= Emerging, 2 or more direct cues given

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




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




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




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




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 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




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


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




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


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




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




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




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




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




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




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




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




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




Chooses where to walk Comments (Date)

Changes shoes if necessary

Changes shirt is necessary


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

Documents

Bathroom Skills/Toilet Use - Structure...Bathroom Skills/Toilet Use Student name: IEP GOAL? Yes No 5= Exceptional, independently completed 2= Emerging, 2 or more direct cues given