1

Modified COPM for StudentsStudent’s Age: _14____Therapist states: For each category state activities that you want to do, need to do, or are expected to do during a typical day. Then rate each activity from 1 (not important) to 10 (very important). Finally, rate each activity by how satisfied you are with your current performance from 1 (not satisfied) to 10 (very satisfied).

Category Identified Activities

Independent

Want to be independent

Important

Self Care Personal Care (e.g.

dressing, bathing, feeding, hygiene)

Change clothes X XBrush teeth X XShower X XBrush Hair X XMake Bed X XDeodorant X X

Functional Mobility (e.g. transfers, indoor, outdoor)

Walks outside X

Community Management (e.g. transportation, shopping, finances)

Goes to church with family

X

Goes to Papa’s house

X

Shop for food X XShop for mom’s b-day

X X

Go to School X X

Productivity Paid/Unpaid Work

(e.g. finding/keeping a job, volunteering)

Helps stock school concession stand

X X

Helps in school kitchen

X X

Household Management (e.g. cleaning, laundry, cooking)

Clean Room X XCook X X

Play/School (e.g. play skills, homework)

Type X XWrite name X XWrite letters X XCook in Kitchen X XTie Shoes X X

Leisure Quiet Recreation

(e.g. hobbies, crafts, reading)

Play with doll XWatch TV XListen to Music X

Active Recreation (e.g. sports, outings, travel)

Run XPlay in Dirt XPlay with Dog X X

Socialization (e.g. visiting, phone calls, parties)

Talk to Joni and Katie at school

X X

2

Modified COPM for StudentsStudent’s Age: _16____Therapist states: For each category state activities that you want to do, need to do, or are expected to do during a typical day. Then rate each activity from 1 (not important) to 10 (very important). Finally, rate each activity by how satisfied you are with your current performance from 1 (not satisfied) to 10 (very satisfied).

Category Identified Activities

Independent

Want to be independent

Important

Self Care Personal Care (e.g.

dressing, bathing, feeding, hygiene)

Shower X XGet dressed X XEat breakfast X XFeed dogs X XSpray Feet X XFeed other Animals X XBrush Teeth X X

Functional Mobility (e.g. transfers, indoor, outdoor)

Walk to friends X XTake the bus to school

X X

Go with friends or aunt

X X

Bike X X

Community Management (e.g. transportation, shopping, finances)

Walk X XHave aunt drive to places

X X

Shopping for hats and clothes

X X

Shopping for groceries

X X

Productivity Paid/Unpaid Work

(e.g. finding/keeping a job, volunteering)

Lunch room X Would like to work for money

X X

Helped in Movie Theater (1 day)

X X

Household Management (e.g. cleaning, laundry, cooking)

Laundry X XClean room X XCooking X XFeed dogs X XTake Dogs Outside X XTake out Trash X X

Play/School (e.g. play skills, homework)

Homework X X XChoir X XWork X X X

Leisure Quiet Recreation

(e.g. hobbies, crafts, reading)

Wii XPlaystation II XListen to Music X XWatch TV X

Active Recreation (e.g. sports, outings, travel)

Basketball XRun X X

Socialization (e.g. visiting, phone calls, parties)

Go to friends X XCall people X X

3

Modified COPM for StudentsStudent’s Age: _16____Therapist states: For each category state activities that you want to do, need to do, or are expected to do during a typical day. Then rate each activity from 1 (not important) to 10 (very important). Finally, rate each activity by how satisfied you are with your current performance from 1 (not satisfied) to 10 (very satisfied).

Category Identified Activities

Independent

Want to be independent

Important

Self Care Personal Care (e.g.

dressing, bathing, feeding, hygiene)

Shower X XLay out Clothes X XGet dressed X XGet everything in book bag

X X

Brush Hair X XBrush Teeth X XEat Breakfast X X

Functional Mobility (e.g. transfers, indoor, outdoor)

Walk or bike to places

X X

Call Cousin X X

Community Management (e.g. transportation, shopping, finances)

Shopping (with friends)

X X

Shop for clothes and groceries with parents

X X

Productivity Paid/Unpaid Work

(e.g. finding/keeping a job, volunteering)

Work in kitchen X XWould like to get a real job

X X

Clean the Law Office X X

Household Management (e.g. cleaning, laundry, cooking)

Dust X XVacuum X XPut clothes away X XFold clothes X XCook X XFeed Dogs X X

Play/School (e.g. play skills, homework)

Homework X XListen to Teachers X X

Leisure Quiet Recreation

(e.g. hobbies, crafts, reading)

Watch tv X XDraw X XListen to Music X XEat Popcorn XWord Searches X XCrossword Puzzles X X

Active Recreation (e.g. sports, outings, travel)

Ride bike XBowling X XWalk around block XWalk to post office X X

Socialization (e.g. visiting, phone calls, parties)

Talk to friends on the phone

X X

Call Cousin X XHang out with Cousin

X X

4

Modified COPM for StudentsStudent’s Age: _19____Therapist states: For each category state activities that you want to do, need to do, or are expected to do during a typical day. Then rate each activity from 1 (not important) to 10 (very important). Finally, rate each activity by how satisfied you are with your current performance from 1 (not satisfied) to 10 (very satisfied).

Category Identified Activities

Independent

Want to be independent

Important

Self Care Personal Care (e.g.

dressing, bathing, feeding, hygiene)

Eat breakfast X XShower X XBrush teeth X XComb hair X XTake Medicine X XTake Vitamins X X

Functional Mobility (e.g. transfers, indoor, outdoor)

Walk outside X XWalk to work X XMom Drives X XWalk home by myself on Thursdays

X X

Community Management (e.g. transportation, shopping, finances)

Get rides from mom X X XShopping for Christmas

X X

Grocery Shopping X (only for 1-2 things)

X

Productivity Paid/Unpaid Work

(e.g. finding/keeping a job, volunteering)

Work in elementary kitchen

X X

Work at hair studio X XWork at Sleep Inn X XWork at Added Touch (Flower Shop)

X X

Household Take out trash X X

Management (e.g. cleaning, laundry, cooking)

Laundry X XCook in oven X XBake X XPut Laundry Away X XClean Room (only if it is a total disaster though)

X X

Play/School (e.g. play skills, homework)

Get homework done on time

X X

Learn X XAsk for Help when Needed

X X

Leisure Quiet Recreation

(e.g. hobbies, crafts, reading)

Listen to Ipod X XRelax X XPlay Nintendo X XWatch Movies X X

Active Recreation (e.g. sports, outings, travel)

Swim X XTake a Walk X X

Socialization (e.g. visiting, phone calls, parties)

Talk on phone X XChat with mom X XTalk to Friends X XGo to Coffee Shop with Friend to Talk

X X

Text X X

5

Modified COPM for StudentsStudent’s Age: _15____Therapist states: For each category state activities that you want to do, need to do, or are expected to do during a typical day. Then rate each activity from 1 (not important) to 10 (very important). Finally, rate each activity by how satisfied you are with your current performance from 1 (not satisfied) to 10 (very satisfied).

Category Identified Activities

Independent

Want to be independent

Important

Self Care Personal Care (e.g.

dressing, bathing, feeding, hygiene)

Get clothes X XBrush hair X XPut hair up X XBrush teeth X XTake Shower X XEat Breakfast X XWatch TV X XWatch for Bus X X

Functional Mobility (e.g. transfers, indoor, outdoor)

Walking XDriving with grandma and grandpa

X X

Bike X X

Community Management (e.g. transportation, shopping, finances)

Shops with grandpa X XShop for Clothes X X

Productivity Paid/Unpaid Work

(e.g. finding/keeping a job, volunteering)

Shovel X XMow X X

Household Laundry X X

Management (e.g. cleaning, laundry, cooking)

Cooking X X XClean Room X XClean Table X XTake out Trash X X

Play/School (e.g. play skills, homework)

Homework X X XDo Work X XFollow Directions X X

Leisure Quiet Recreation

(e.g. hobbies, crafts, reading)

Watch TV XListen to music XRead X XDo Puzzles X X

Active Recreation (e.g. sports, outings, travel)

Hunt X XHorseback riding XPlay Football Take WalksWalk Dog X

Socialization (e.g. visiting, phone calls, parties)

Talk on the phone X XHang out with Friends

X X

6

Modified COPM for StudentsStudent’s Age: _20____Therapist states: For each category state activities that you want to do, need to do, or are expected to do during a typical day. Then rate each activity from 1 (not important) to 10 (very important). Finally, rate each activity by how satisfied you are with your current performance from 1 (not satisfied) to 10 (very satisfied).

Category Identified Activities

Independent

Want to be independent

Important

Self Care Personal Care (e.g.

dressing, bathing, feeding, hygiene)

Brush teeth X XPut on clothes X XComb hair X XPuts on deodorant X XMake Bed X XTake medication X X

Functional Mobility (e.g. transfers, indoor, outdoor)

Walks X XDrive with Learners Permit

X X X

Ask Mom for Ride X X

Community Management (e.g. transportation, shopping, finances)

Walks places X XDrives (learners permit)

X X X

Productivity Paid/Unpaid Work

(e.g. finding/keeping a job, volunteering)

Good Sam (Nursing home)

X X

High School Kitchen X XEventually work on own

X X

Cleaned Law Office X X

Household Take out trash X X

Management (e.g. cleaning, laundry, cooking)

Clean Bathroom X XVacuum X XDishes X XLaundry X XIron Clothes X XCooks X X

Play/School (e.g. play skills, homework)

Works during school hours

X X

Gets work done at school

X X

Lean to Read Ads X X XLife-Skills Work X XJob Stuff X XTime X X X

Leisure Quiet Recreation

(e.g. hobbies, crafts, reading)

Watch TV XListen to Music XSpell Words X X

Active Recreation (e.g. sports, outings, travel)

Go on Walks X XGo Bowling X X

Socialization (e.g. visiting, phone calls, parties)

Talk on phone X XTalk to Friends at Life-Skills

X X

Play Games X XMeet at Coffee Shop X X

7

Modified COPM for StudentsStudent’s Age: _16____Therapist states: For each category state activities that you want to do, need to do, or are expected to do during a typical day. Then rate each activity from 1 (not important) to 10 (very important). Finally, rate each activity by how satisfied you are with your current performance from 1 (not satisfied) to 10 (very satisfied).

Category Identified Activities Independent

Want to be independent

Important

Self Care Personal Care (e.g.

dressing, bathing, feeding, hygiene)

Get up X XShower X XGet clothes X XEat breakfast X XBrush teeth X XShave X XFeed Dogs X XFeed Animals X XTake Medicine X X X

Functional Mobility (e.g. transfers, indoor, outdoor)

Have Aunt Drive Me X XWalk X XBus X XRide with Friends X X

Community Management (e.g. transportation, shopping, finances)

Grocery shopping X X XPay Bills with Money From State

X X X

Productivity Paid/Unpaid Work

(e.g. finding/keeping a job, volunteering)

Work in the lunchroom X XHelp at Movie Theater (1 day)

X X X

Household Management (e.g. cleaning, laundry, cooking)

Laundry (only when aunt is home)

X X

Cooking X XCleaning X XDo Dishes X XFeed animals X X

Play/School (e.g. play skills, homework)

Homework X XHelp Teachers When They Need It

X X

Leisure Quiet Recreation

(e.g. hobbies, crafts, reading)

Watch TV XListen to music XWatch Movies XNap X X

Active Recreation (e.g. sports, outings, travel)

Run X XPlay basketball X XGo Fishing X X

Socialization (e.g. visiting, phone calls, parties)

Hang out with friends X XTalk on the phone XText friends X X