Project SEARCH Froedtert Hospital – Adult Program

2015-2016 Applicant Name: ____________________________________ DVR counselor Name: _________________________________________ Case Manager Name/Agency: ___________________________________

Date Received (official use only) _____________________________________________________________

APPLICATION PURPOSE AND GUIDELINES The purpose of this application packet is to outline the skill set of the Project SEARCH candidate. This application enables the Selection Committee* to properly assess each candidate’s skills, abilities and background. A parent, candidate, counselor, teacher or employer may be contacted by the Selection Committee to gather additional information. Our goal is to select candidates who will be successful in the Project SEARCH program and reach the outcome of competitive employment. Project SERACH Froedtert Hospital will run October 5th, 2015 – June 30th, 2016 The Selection Process includes the following guidelines:

1. All candidates are encouraged to attend an Open House or visit the Project SEARCH site to

view the possible rotations and meet the Project SEARCH staff.

LIST DATE VISITED: _______________ LIST LOCATION VISITED:_____________

2. Submit the completed application packet by July 10th 2015 to:

Beth Lohmann, Easter Seals SE Wisconsin

3. The Selection Committee will review the applications, and if the eligibility criterion is met,

Project SEARCH staff will schedule a phone assessment to confirm eligibility, discuss application and next steps.

4. Once the phone assessment is completed and the candidate is found eligible they will move

to the next phase of selection. The candidate will be asked to interview with the selection team. The Selection Committee will use a rubric scale to pick the candidates that will be successful in the program.

5. If accepted, candidates must be able to pass a criminal background check, physical and drug

screen. Please note:

The Selection Committee will include a Project SEARCH staff, representatives from Froedtert Hospital, Division of Vocational Rehabilitation representatives and the local school districts involved.

Eligibility Criteria:

1. Candidates within eligible age range (25-35 age range) 2. Candidates who desire to work competitively at the end of the Project SEARCH program 3. Candidates who are eligible for long term support 4. Candidates who will benefit from participation in a variety of internships 5. Candidates who are independent of self cares and medication management 6. Candidates who are not harmful to self or others 7. Candidates that can self monitor on a 1:4 ratio of support 8. Access to independent transportation to/from the Project SEARCH program

APPLICATION PACKET CHECK LIST *PLEASE NOTE* ALL THE REQUIRED DOCUMENTS MUST BE COMPLETED AND SUBMITTED TOGETHER FOR CONSIDERATION BY JULY10th 2015

Completed Application Packet

Photo

Immunization Record - Copy

Functional Screen (Family Care) and/or Individual Plan for Employment (IPE) and/or Functional Assessment from DVR.

Current Evaluation Team Report or Vocational Evaluation- documentations of most recent math and reading scores/grade levels (if available)

High School Transcript or other formal training (if available)

Two letters of recommendation from School Representative, Employer or Volunteer Placement

Letter from DVR confirming funding and DVR Counselor’s name

Letter from IRIS/Family Care to confirm funding and contact person

Parent and Candidate self preparation assessment forms (included with application packet)

Resume

Return completed Packet to:

Beth Lohmann Easter Seals SE Wisconsin 505 Northview Road Waukesha, WI 53188 262-953-2208 bethl@eastersealswise.com

Criminal Background Check and Drug Screen will need to be completed for accepted candidates.

APPLICATION FOR PROJECT SEARCH

CANDIDATE INFORMATION: Name: _________________________________________________________________________________ Address: _______________________________________________________________________________ Home Number : _________________________ Cell Number: ___________________________________ Candidates Email: ________________________________________________________________________ FAMILY INFORMATION: Mom’s Name: _____________________________ Mom Email: _________________________________ Mom Cell Number: __________________________ Mom Work Number: __________________________ Address (if different then above): ____________________________________________________________ Dad’s Name: ______________________________ Dad Email: ___________________________________ Dad Cell Number: ___________________________ Dad Work Number: ____________________________ Address (if different then above): ____________________________________________________________ Parent/Candidate Information:

1. Release: The candidate’s records concerning my son/daughter will be shared with Easter Seals and Project SEARCH Staff.

2. Equal Opportunity: Project SEARCH placement will be made without regard to race, color, national origin, gender, age, religion or presence of a disability.

A thirty day trial period will be required of all accepted interns. The parent and intern agree to comply with this procedure. Parent/Guardian Signature: Date:

Candidate Signature: Date:

APPLICATION FOR PROJECT SEARCH

EMPLOYMENT PREFERENCES and BACKGROUND: How do you want to be employed in the community upon completion of Project SEARCH? Full time Part time Which shift would you prefer working after completing Project SEARCH? 1st Shift 2nd Shift 3rd Shift Would you be willing to work holidays and/or weekends? Yes No Do you plan to work during the program year, in addition to being in the Project SEARCH Program? Yes No

If yes where? How many days/ hours?

Are you considering post secondary education options? Yes No If Yes please describe your plan, goal for future schooling and time frame: ___________________________ Please list paid employment experience

Employer Job Title Job Duties Supervisor Name/Number Dates of Experience

1. 2. 3.

1. 2. 3.

1. 2. 3.

Please list volunteer and NON paid work experiences.

Agency Job Title Job Duties Supervisor Name/Number Dates of Experience

1. 2.

1. 2.

1. 2.

How many days did you miss work at your current or last job?

None 1-5 5-10 More then 10 Have you ever been fired from a job? Yes No If yes, please explain: ____________________________________________________________________ Have you ever quit a job? Yes No If yes, please explain: _____________________________________________________________________

APPLICATION FOR PROJECT SEARCH

SERVICE AGENCIES: List your DVR Counselor: Name: _______________________ Phone Number: ________________________ List your long term funding and Contact name: Family Care Care Manager: ___________________ Phone Number: ______________ IRIS IRIS Consultant: ___________________ Phone Number: ______________ Private Pay (Letters to confirm funding sources are required with completed applications)

List any other Support people in your life: Name: ___________________ Phone Number: ________________ Relationship: ________________ Name: ___________________ Phone Number: ________________ Relationship: ________________

INDEPENDENT LIVING: ** Please include all medical information as it will help us recognize what types of support the candidate will need if accepted to the program. Medications/ dosage/ Time of day taken by student

Medication Dosage Time of day

List any health or medical issues that may impact the candidate during the Project SEARCH Program. (Seizures, Diabetes, Anxiety, Depression, Sleep Disorder, etc.):

Please list any limitations that may need accommodation or impact employment:

BEHAVIORAL SUMMARY: Do you have any behaviors that need to be supported in order to have a successful job placement? Yes No Please Explain:

APPLICATION FOR PROJECT SEARCH

CANDIDATES RESPONSE QUESTION

Why do you want to come to Project SEARCH? (Candidate should write in their own words)

List Four References:

Name Type of Reference

Phone Number Email Address

1.

Family Reference

2.

School Reference

3. Other Community or Agency Reference

4. Employer or Volunteer Supervisor

The person assisting the candidate to complete this application is:

Name Title Phone Number Date

Organization Phone Number Email contact

Signature

Project SEARCH Intern Contract

I, ___________________________, understand that I have been accepted into the Project SEARCH Adult Program and must abide by the following terms and conditions:

I will complete at least three job rotations within the host business.

I will attend the program every day from 8:00 am-2:30 pm, Monday through Friday.

I will maintain at least 95% attendance.

I understand that the Project SEARCH program is a nine month work experience training program.

I will dress appropriately and wear required attire.

I will call my Project SEARCH Staff and departmental supervisors when I am absent or tardy.

I understand that I am responsible for transportation to the host site.

I will follow all the rules established by the program and host business.

I will attend scheduled meetings with my DVR counselor, parents, and Project SEARCH staff.

I will be an active participant and communicate any issues at our meetings.

I will actively pursue employment.

I have read the above terms and conditions and agree to accept my placement in the Project SEARCH program. I understand that I may be asked to leave Project SEARCH if I fail to follow the terms and conditions. ____________________________________ ____________________________ Intern Signature Date ____________________________________ ____________________________ Parent/Guardian Signature Date

*The intern will be asked to sign this upon acceptance into the program at the orientation meeting.

Project SEARCH Preparation – Parent/Care Giver Assessment

Project SEARCH Preparation – Parent/Care Giver Assessment

Candidate Name:

Date Completed:

Name of person filling out form:

Relationship to Candidate:

Please be honest when filling out this information to help us determine eligibility and the level of support the candidate may need if selected for Project SEARCH. Commitment to Community Employment (check all that apply)

Candidate wants to get a job

The family supports the goal of competitive community employment

Candidate can be contacted through an answering machine or voice mail

Candidate has actively searched for jobs Independent Daily Living and Self Care Skills (check all that apply)

Candidate is independent in daily living and self care skills

Prepare a lunch or snack

Understands healthy food choices

Maintain checkbook

Handling Money/making change

Taking Medication

Toileting

Daily Shower/Bath without reminders

Read a digital clock and tell time

Read a clock and tell time

Make an appointment by phone

Be at home alone

Able to stay awake for a 6-8 hour day Appearance and Professional Presentation (check all that apply)

Candidate arrives at school and/or work daily with:

Clean and combed hair

Clean clothing and underwear

Brushed teeth/oral hygiene

Clean clothes

Candidate wears appropriate clothing for the weather

Candidate follows the school or work dress code

Candidate willingly follows the designated dress code of my employer including rules on:

Appropriate clothing

Shoes

Facial hair

Facial and body piercings

Tattoos

Jewelry

Fingernail polish and length Transportation (check all that apply)

Candidate has his/her own car, drivers license and insurance

Candidate knows how to use public transportation

Candidate can read a bus schedule

Candidate is willing to learn to use public transportation

Candidate uses a door-to-door or para-transit system independently o _____ Parent or other guardian makes appointment for candidate o _____ Candidate makes own appointments

Candidate is able to pay for transportation as needed

Candidate has a family member/other who is willing to provide on-going transportation

Other transportation options ____________________________________________ Appropriate Social and Behavior Skills (check all that apply)

Candidate has not been talked to or disciplined because of inappropriate touching or public displays at school or work

Candidate does not swear or use profanity in a school or work setting

Candidate shows respect to peers and adults

Candidate works cooperatively with others

Candidate accepts correction and criticism without a negative reaction

Candidate has appropriate behavior with adult supervision but may not be appropriate in all independent situations (or needs some adult prompts on an on-going basis)

Candidate has lost temper in a school or work environment

Candidate has acted aggressively in a school or work setting

Screaming or yelling

Hitting/Punching

Spitting

Kicking

Fighting Interpersonal Communication (check all that apply)

Candidate responds when someone speaks or asks questions

Candidate makes eye contact

Candidate uses an appropriate tone of voice

Candidate is comfortable starting a conversation with someone

Candidate engages in appropriate conversation in a school or work environment

Candidate uses appropriate body language in the school or work environment

No inappropriate hand gestures

Sitting appropriately in a chair / posture

Respecting personal space

Candidate uses a cell phone and electronic equipment (IPOD, Walkman, Bluetooth, etc). appropriately according to the school or business policy including refraining from talking and answering the phone, texting and listening to music

Verbal Communication (check all that apply)

Candidate is easily understood by others

Candidate sometimes has trouble getting message across to others

Candidate uses adaptive equipment to communicate

Candidate is willing to learn to use adaptive equipment to communicate if appropriate

Candidate uses an interpreter and/or uses sign language to communicate

Candidate talks about the same topics over and over again Recreational Activities (check all that apply) Candidate participates in organized group activities:

Sports (please list)_________________________________________________

Band

Choir

Theatre

Scouts

Church youth group

Community recreation and/or Special Olympics

Computer or electronic games

Other ___________________________________________________________ Candidate likes to exercise on own (walking, running, biking, etc.)

Exercises _________ each week for at least thirty minutes each time Candidate enjoys sit-down activities such as:

Computer or electronic games

Watching television

Reading

Scrap booking

Other _________________________________________________________ Candidate has the following hobbies: ______________________________________________ Physical Limitations (check all that apply)

Candidate has difficulty walking Candidate uses the following to walk/navigate:

Cane

Walker

Wheelchair

Scooter

Other

Candidate has limited use of arms and/or hands

Candidate has other physical limitations that may affect employment. Please list: ______________________________________________________________________

______________________________________________________________________

Production Rate and Work Quality (check all that apply)

At work, volunteer or program, candidate completes all tasks with high quality by due date

At work, volunteer or program completes all tasks with average quality by due date

At work, volunteer or program, candidate completes all tasks with poor quality by due date

At work, volunteer or program, candidate turns in assignments by deadline or due date

At work, volunteer or program, it is difficult for the candidate to get all tasks finished or turned in on time

Please list strategies that have assisted the candidate to complete and turn in work on time _______________________________________________________________________

_______________________________________________________________________

At work, volunteer or program the candidate gets most of the tasks correct

If no, please explain: __________________________________________________

With home chores or on the job the candidate’s work is organized and neat

Other comments: _____________________________________________________ Employability Skills (check all that apply)

Candidate gets to work or other appointments on time and independently

After lunch or a break, the candidate gets back to class or work on time

The candidate knows how to tell and keep track of time

The candidate is able to count money and make change accurately

The candidate stays on a task until it is finished

If interrupted, the candidate can return to the task and finish it

The candidate can access personal information to complete a paper application

The candidate has had experience with completing on-line applications

The candidate knows how to answer common interview questions

The candidate can tell his/her boss or co-workers what help is needed on their job

Please list strategies that have been successful and leads to success and independence: o _________________________________________________________________

o _________________________________________________________________

o _________________________________________________________________

Prior Work Experience (check all that apply)

The candidate has worked at their school doing: _______________________________________________________________________

The candidate has volunteered at: _______________________________________________________________________

The candidate does the following chores at home on a regular basis: _______________________________________________________________________

The candidate has never worked or volunteered

Academic Skills (check all that apply)

The candidate’s favorite subjects in high school were/are: ___________________________

The candidate likes to read books for pleasure. The last book read was: _______________

The candidate uses a calculator when doing math problems or for everyday use

The candidate likes to read the newspaper and magazines for news, job hunting and other information

The candidate likes to write or keeps a diary/journal Computer/Electronic Skills (check all that apply)

The candidate has basic keyboarding skills and uses correct typing techniques

The candidate has basic keyboarding skills and uses only two fingers (hunt and peck)

The candidate can use Microsoft Word to create letters and other documents

The candidate can use Microsoft Excel to create spreadsheets and other documents

The candidate can use Microsoft Publisher to create cards, newsletters, flyers or other documents

The candidate can use email correctly

The candidate can access the internet to get information, find services such as map quest and use various search engines

The candidate uses a computer to play games, watch TV shows, listen to on-line streaming, etc.

The candidate has minimal computer skills

The candidate uses a cell phone to talk to others

The candidate uses a cell phone for texting Additional School and Community Supports (check all that apply) The candidate receives Related Services through the school district

Speech Therapy

Occupational Therapy

Physical Therapy

Other Problem Solving and Conflict Resolution Please give us some examples of the candidate’s problem solving abilities and/or how they handle conflict: Home situation: School situation: Community or work situation:

Project SEARCH Preparation – Candidate Self Assessment

Project SEARCH Preparation – Candidate Self Assessment

Name:

Date Completed:

Dear Project SEARCH Candidate: We encourage you to fill out this assessment independently and in your own words. Fill out each section with the best information about yourself and your skills, that will help us learn more about you. We look forward to meeting you.

The Project SEARCH Staff

Commitment to Community Employment (check all that apply)

I want to get a job

My family supports my goal of competitive community employment

I have actively searched for jobs

I access to email and voicemail where an employer can each me Independent Daily Living and Self Care Skills (rate each area by circling the appropriate number)

On a scale of 1 – 5, how competent are you in each of these areas:

not very good good very good Prepare a lunch or snack 1 2 3 4 5 Understand what foods are good for me 1 2 3 4 5 Maintain my own checkbook 1 2 3 4 5 Handling Money/making change 1 2 3 4 5 Taking Medication 1 2 3 4 5 Toileting 1 2 3 4 5 Daily Shower/Bath without reminders 1 2 3 4 5 Read a digital clock and tell time 1 2 3 4 5 Read a clock and tell time 1 2 3 4 5 Make an appointment by phone 1 2 3 4 5 Be at home alone 1 2 3 4 5 Able to stay awake for a 6-8 hour day 1 2 3 4 5

Explain any areas that you may need assistance with

_______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________

Appearance and Professional Presentation (check all that apply)

I arrive at school and/or work daily with:

Clean and combed hair

Clean clothing and underwear

Brushed teeth/oral hygiene

Clean clothes

I wear appropriate clothing for the weather

I follow my school or work dress code

I am willing to follow the designated dress code of my employer including rules on:

Appropriate clothing

Shoes

Facial hair

Facial and body piercings

Tattoos

Jewelry

Fingernail polish and length

Transportation (check all that apply)

I have reliable transportation to get to work

I have my own car, drivers license and insurance

I know how to use public transportation

I can read a bus schedule

I am willing to learn to use public transportation

I use a door-to-door or para-transit system independently and can make my own appointments

I use a door-to-door or para-transit system and a family member/other person helps to make the appointments

I have a family member/other who is willing to provide on-going transportation

I am able to pay for transportation as needed

Other transportation options ____________________________________________________ Appropriate Social and Behavior Skills (check all that apply)

I have never been talked to or disciplined because of my inappropriate touching or public displays of affection at school or work

I do not swear or use profanity in a school or work setting

I show respect to my peers and adults

I work cooperatively with others

I accept correction and criticism without a negative reaction

I have lost my temper in a school or work environment

I have displayed aggressive behavior in a school or work setting

Screaming or yelling

Hitting/Punching

Spitting

Kicking

Fighting Interpersonal Communication (check all that apply)

I respond when someone speaks or asks questions

I make eye contact

I use an appropriate tone of voice

I am comfortable starting a conversation with someone

I engage in appropriate conversation in a school or work environment

I use appropriate body language in the school or work environment

No inappropriate hand gestures

Sitting appropriately in a chair / posture

Respecting personal space

I use a cell phone and electronic equipment (IPOD, Walkman, Bluetooth, etc). appropriately according to the school or business policy including refraining from talking and answering the phone, texting and listening to music

Verbal Communication (check all that apply)

I am easily understood by others

I sometimes have trouble getting my message across to others

I use adaptive equipment to communicate

I am willing to learn to use adaptive equipment to communicate if appropriate

I use an interpreter and/or use sign language to communicate

I talk about the same topics over and over again

Recreational Activities (check all that apply) I participate in organized group activities:

Sports _________________________________________________________

Band

Choir

Theatre

Scouts

Church youth group

Community recreation and/or Special Olympics

Computer or electronic games

Other __________________________________________________________ I like to exercise on my own (walking, running, biking, etc.)

I exercise _________ each week for at least thirty minutes each time I like sit-down activities such as:

Computer or electronic games

Watching television

Reading

Scrap booking

Other ____________________________________________________ I have the following hobbies: ________________________________________________ Physical Limitations (check all that apply)

I have difficulty walking Describe ___________________________________________________________ I need to use the following to help me walk/navigate:

Cane

Walker

Wheelchair

Scooter

Other

I have limited use of my arms and/or hands Describe__________________________________________________________

I have other physical limitation that may affect employment: Please list: _________________________________________________________________

Production Rate and Work Quality (check all that apply)

At work, volunteer or program, I get all my tasks finished on time with high quality and I turn in by the due date

At work, volunteer or program, I get all my tasks finished on time with average quality and I turn in by the due date

At work, volunteer or program, I get all my tasks finished on time with poor quality and I turn in by the due date

At work, volunteer or program, it is difficult to get all my tasks finished or turned in by the due date

At work, volunteer or program I am often asked to re-do work

On chores or on my job my work is organized and neat

Employability Skills (check all that apply)

I get to school, work or other appointments on time and independently

After lunch or a break, I get back to class or work on time

I know how to tell and keep track of time

I stay on a task until it is finished

If I am interrupted, I can return to the task and finish it

I can access the necessary information to fill out a paper application

I can have experience in filling out an on-line application

I know how to answer common interview questions

I can tell my boss or co-workers ways that I learn best or tools that help me be a good worker

Please list ways that help you learn best or tools you use to be successful at school or on the job: _____________________________________________________________________ _____________________________________________________________________

Prior Work Experience (check all that apply)

I have worked at my school doing: _________________________________________

I have volunteered at: ___________________________________________________

I do the following chores at home on a regular basis

Academic Skills (check all that apply)

I like to read books for pleasure. The last book I read was: _____________________

I use a calculator when I do math problems or for everyday use

I like to read the newspaper and magazines for news, job hunting and other information.

I like to write or keep a diary/journal Computer/Electronic Skills (check all that apply)

I have basic keyboarding skills and use correct typing techniques.

I have basic keyboarding skills and use only two fingers (hunt and peck).

I can use Microsoft Word to create letters and other documents

I can use Microsoft Excel to create spreadsheets and other documents

I can use Microsoft Publisher to create cards, newsletters, flyers and other documents

I can use email correctly

I can access the internet to get information, find services such as map quest and use various search engines

I use a computer to play games, watch TV shows, listen to on-line streaming, etc.

I have no computer skills

I use a cell phone to talk to others

I use a cell phone for texting School and Community Supports (check all that apply) I receive Related Services through my school district

Speech Therapy

Occupational Therapy

Physical Therapy

Other

Problem Solving and Conflict Resolution: Please give us some examples of how you would solve these problems. If someone writes the answers for you, have them do it in your own words.

I missed my bus ride when I was going someplace. To get where I was going I would do the following: I was sweeping (vacuuming) and the sweeper quit working or got clogged. In order to finish my task I would do the following: I lost my house key. In order to get in my house I would do the following:

I was using my computer and it stopped working. I would try to: My parents were not home. It was dinner time and I was hungry. What would I do?

Someone teased me or was mean to me. I would react by:

Thanks for your work to finish this assessment! We appreciate it.