_____ Plans own meals

_____ Does own grocery shopping/ puts groceries away at home

_____ Prepares own meals

_____ Sets the table

_____ Gets food to table/ eats independently

_____ Cleans up kitchen/ refrigerate leftovers/ washes dishes & puts them

away/ washes table / stove/ counter tops

COMMENTS:

________________________________________________________________

_____ Collect/ sorts dirty clothes

_____ Puts clothing/ detergent in machine/ starts washer

_____ Puts clean clothing into dryer/ starts dryer

_____ Folds/ hangs up/ puts away clean clothing

COMMENTS:

_____ Change bedding/ make bed

_____ Vacuuming/ sweeping/ mopping floors

_____ Dusting

_____ Cleaning windows/ patio doors

_____ Cleaning bathroom; toilet/ bathtub/ shower/ lavatory

_____ Cleaning kitchen ; stove & refrigerator

COMMENTS:

________________________________________________________________

_____ Understands difference between income and expense

_____ Knows current sources of income, knows amount of income

_____ Sets priorities for spending; rent/ house payment/ utilities/ food/ clothing

etc.

_____ Has a checking account

_____ Deposits own check

_____ Writes check for necessary expenses or purchases

_____ Balances own checkbook

_____ Uses ATM independently

_____ Pays necessary expenses first

COMMENTS:

________________________________________________________________

_____ Can get undressed independently

_____ Can get into tub/ shower, bathe & shampoo hair independently

_____ Can get clothing and get dressed independently

_____ Can comb hair/ shave/ apply make-up independently

COMMENTS:

________________________________________________________________

_____ Knows the relationship between proper care and good health

_____ Knows how & who to contact for health/ first aid emergency

_____ Knows how to treat minor healthcare situations

COMMENTS

________________________________________________________________

_____ Understands differences in Subsidized vs. Fair Market housing

_____ Knows how to get and complete subsidized housing application

_____ In a rental situation, identifies/ understands responsibilities of/

differences in/ rights of;

_____ Tenant/ Landlord

_____ Rent

_____ Lease

_____ Eviction

_____ Deposit/ Utilities; included or extra

• When looking for an apartment/ home to rent,

_____ Is able to look through and understand rental listings in newspaper and

other publications

• Options to consider when looking for an apartment;

_____ Location;

_____ Proximity to bus route

_____ Proximity to shopping

_____ Pros/Cons of having a room mate

_____ One/two bedroom

_____ Monthly rent that fits budget

_____ Lease requirements

• Understands other housing options besides renting an apartment;

_____ Boarding housing

_____ Share-a-home

_____ Other

COMMENTS:

_______________________________________________________________

_____ Identifies the options for public transportation; bus/ dial-a-ride /taxi

_____ Is able to read the bus book & identify which bus to take

_____ Is able to use accessible bus and related equipment

_____ Is able to get dial-a-ride/ ADA paratransit card

COMMENTS:

________________________________________________________________

_____ Is able to respond to fire in home

_____ Call 911

_____ Use appropriate fire extinguisher

_____ Evacuate premises

• Knows what to do in other situations;

_____ Respond to severe storm warning

_____ Home invasion/ break-in

_____ Toast stuck in the toaster

_____ Radio by the bathtub/ sink

_____ Sparks/ smoke coming from electric appliance

_____ Emptying ashtrays

_____ Toilet overflowing

_____ Locked self out of home

_____ Spoiled/ questionable food

_____ Abuse/ neglect by anyone; verbal or physical

COMMENTS:

________________________________________________________________

_____ Has back-up in case of no-show

_____ Organize and direct duties to make the most of time allowed

_____ Knows person/ phone number to call if problems exist

COMMENTS:

________________________________________________________________

_____ Is able to use telephone

_____ Knows number for bus information

_____ Knows number for library/ recreation

_____ Knows number for Emergencies; 911

_____ Knows name and number of apartment manager

_____ Knows number for Utility Company/ Plumber

_____ Knows number for DMV

_____ Knows number for voter information

_____ Knows number for food stamp/ financial benefit/ case manager office

• Identifies/ uses tools available for locating community resources;

_____ Telephone book

_____ Community I&R

_____ Newspaper

COMMENTS:

_______________________________________________________________

_____ Has/ knows who to contract for training/ education

_____ Answers questions regarding/ prioritizes job development

_____ Knows how/ where to look for jobs

_____ Identifies areas of interest

_____ Can develop a job search

_____ Can develop a resume

COMMENTS:

_______________________________________________________________

ON EMPLOYMENT

• Interviewing for a job;

_____ Identifies appropriate appearance

_____ Identifies pertinent information to take

_____ Identifies appropriate questions to ask

_____ Identifies appropriate interview behaviors

• On the job;

_____ Identifies appropriate work behaviors

_____ Identifies appropriate employer/ employee interaction

_____ Identifies appropriate interaction with co-workers

_____ Identifies appropriate interaction with customers

COMMENTS:

______________________________________________________________

_____ Satisfied with present use of free time

_____ Would rather spend free time alone

_____ Would rather spend free time with others

_____ Would rather watch activities

_____ Would rather participate in activities

_____ Would rather participate indoors

_____ Would rather participate outdoors

_____ Would rather participate in noisy events

_____ Would rather participate in quiet events

_____ Already has enough friends/ acquaintances

_____ Has trouble making friends

_____ Has trouble keeping friends COMMENTS:

_____ Communicates personal information; name/ address/ phone number

_____ Communicates needs

_____ Initiates interactions

_____ Responds to verbal contact

_____ Complies with; directions from staff/ group decisions/ scheduled activities

_____ Takes responsibility for self

_____ Exhibits socially acceptable behavior

• Appropriate personal hygiene in;

_____ General appearance

_____ Hair care

_____ Dental care

• Takes responsibility for;

_____ Getting to location on time

_____ Medication regimes

_____ Locating items

• Exhibits socially acceptable behavior in the following situations;

_____ When eating with others

_____ When angry

_____ When meeting someone

_____ When in public places

_____ When receiving criticism/ correction

_____ When receiving a compliment

_____ When making a request

_____ When expressing thanks

_____ When its time to go home

COMMENTS:

________________________________________________________________

• Describes the physical differences between men and women

_____ Defines masturbation/ intercourse

• Answers questions regarding pregnancy correctly

_____ How pregnancy occurs

_____ When pregnancy occurs

_____ Signs of pregnancy

_____ Length of pregnancy

• Answers questions regarding birth control

_____ Pregnancy prevention

_____ Methods of birth control/ most reliable method

• Answers questions regarding sexually transmitted diseases;

_____ Defines STD’s

_____ Describes symptoms of STD’s

_____ Explains preventative measures

_____ Offers plan of action to prevent STD’s

• Answers questions regarding AIDS/HIV

_____ Defines AIDS/HIV

_____ Explains how AIDS/HIV is transmitted

_____ How to know if partner has AIDS/HIV

_____ Knows how AIDS/HIV is diagnosed

• Answers questions regarding safe sex;

_____ Defines "safe sex"

_____ Understands the importance of "safe sex"

_____ Knows how people can have "safe sex"

• States they think they know enough about sex

COMMENTS: