Post School Survey
2015 - 16 Pennsylvania Post School Outcomes Survey Timeline & Procedures # Cohort 5 - Post School Survey Materials The following materials are included in your Cohort 3 Post School Survey Packet:
List of Students for Whom the LEA Needs to Complete a Post School Survey
Former Student Leaver’s Contact Information and Pre-populated Post-School Survey Forms
Annotated Instructions for Post School Survey Completion
IU and PaTTAN Transition Consultants’ Support Structure for PaPOS 2015-2016
Contacting Hard -to-Find Youth: Strategies for the Post-School Survey
Strategies to Contact Youth for the PaPOS Process: Lessons from Pennsylvania Schools
UPS Mailing Labels
Procedures: The following are procedures for targeted Cohort 5 LEAs to complete the Post School Survey:
Contact all former student leavers no earlier than one year after the students left school through no later than September 30, 2016 o
Former student leavers are graduates, dropouts, and students who aged out who had IEPs during the 2014-15 school year.
Make 3 unique attempts at contacting all former student leavers. It is required that these attempts be made on different days and/or utilize a variety of communication methods.
Submit completed surveys to PaTTAN Pittsburgh: o
Make a copy of the surveys for your records.
o
Return the completed original colored surveys to PaTTAN Pittsburgh based on the submission target dates indicated on the back of this form.
o
Retain your UPS tracking receipt for your records. To contact UPS for a direct pickup at your building call 1-800-PICK-UPS (742-5877). 1
If you have any questions or concerns regarding the PaPOS process for this year, please send an email to: [email protected]
Submission Target Dates DATE
MATERIAL
7/15/16
First submission of all completed Post surveys to date from Cohort 5 LEAs mailed to PaTTAN Pittsburgh via UPS.
8/15/16
Second submission of all completed Post surveys to date from Cohort 5 LEAs mailed to PaTTAN Pittsburgh via UPS. Recommendation: 50% of surveys due to PaTTAN
9/30/16
Final submission of all completed Post surveys from Cohort 5 LEAs mailed to PaTTAN Pittsburgh via UPS.
2
PENNSYLVANIA POST SCHOOL SURVEY
2015-16 – Cohort 5 Annotated Instructions The following annotated instructions correlate to the 2015-16 PaPOS Post School Survey. Please review prior to conducting the PaPOS Post School Survey with your former student leavers. Administrative Considerations The Post School Survey should be administered in an interview fashion by an individual familiar with the student being interviewed. If a student’s disability limits his/her ability to respond accurately to the survey questions, an individual (e.g., family member, provider agency staff, etc.) can assist the student in answering the student survey questions. At the conclusion of the survey, make a copy of the completed survey. Mail the original survey to PaTTAN Pittsburgh based on the schedule provided in the 2015-16 Pennsylvania Post School Outcomes Survey Timeline & Procedures document. The Timeline & Procedures document is included in your materials packet. Former Student Leaver’s Contact Information Sheet – Page 1 This information was entered last year as part of the 2014-15 PaPOS Exit Survey. It should be used to contact the former student. Contact information should have been entered for both the former student and his/her primary contact. If the contact information is incomplete or is incorrect to the extent that you cannot reach the student nor his/her primary contact, refer to the most recent student records for correct information. (The LEA is required to make every reasonable attempt to contact the former student.)
3
District: xx SD
Former Student’s Contact Information: Former Student’s Name: Jane Doe Home Phone: 2165319086 Cell Phone: 2165232899 Email Address: [email protected] Street Address: 543 MAIN ST City: VINTON State: PA Zip code: 15961
Primary Contact Information: Contact’s Name: John Doe Relationship to former student: Father Home Phone: 2165319086 Cell Phone: Email Address: Street Address: 543 MAIN ST City: VINTON State: PA Zip code: 15961
If the contact information is incorrect or is missing, refer to the student’s school records. 4
Former Student’s Demographic Information - Page 3 Demographic information was provided when the Exit survey was completed at the end of the 2014-15 school year. The information includes the former student’s LEA, last name, first name, PA Secure ID, and Date of Birth. If any of the demographic information is incorrect, please make the correction on the survey form in Red Ink.
Former Student’s Demographic Information Former Student’s LEA Former Student’s Name
Steel City SD
Jones
Bob
Last Name
First Name
Former Student’s PA Secure ID
Former Student’s Date of Birth MM/DD/YYYY
222222222
8/22/1998
Record of Attempts to Contact – Page 3 LEAs are required to make 3 unique attempts to contact each former student leaver. Attempts must be made on different days and/or utilizing a variety of communication methods (e.g., telephone calls, mailing, internet contact, etc.). Contact information provided on last year’s exit survey appears on the Student’s Contact Information Sheet (Page 1) of each former student’s PaPOS Post School Survey Form. If the information is incomplete or inaccurate to the degree that the student cannot be reached, refer to the most recent school record for the student. Contact all former leavers no earlier than one year after the student left school through no later than September 30, 2016 Record if you were able to complete the survey. If you did not successfully contact the student/contact person or if he/she refused to be interviewed, select “No”. Were you able to complete the survey?
Yes No
X 5
Select the reasons why the interview could not be completed. Check as many reasons as apply. If the survey was completed successfully, select N/A. Check ALL that apply
Why was the survey unable to be completed?
Contact information was not correct Person declined to be interviewed or did not respond to request Former student is deceased
X X
N/A Survey was completed
Record the dates when you attempted to contact the student to complete the survey. Make sure that all the dates listed occurred at least one year AFTER the student left school. On what dates did you attempt the survey? Attempt Date of Attempt 1 07/01/2016 2
07/15/2016
3
09/01/2016
If you are unable to complete the survey after 3 attempts, you have fulfilled the requirement for the Post School Survey for this former student. Complete the 3 survey questions on page 3 and submit the survey to PaTTAN Pittsburgh. Characteristics of Interviewer – page 4 This section marks the beginning of the Post Survey questions. Please begin by selecting the primary role of the interviewer and identifying the person who was interviewed. Select only one option for each item. Check only ONE option Teacher
X
Administrator Transition personnel
Primary Role of Interviewer
Paraprofessional/education assistant School psychologist School counselor Other Please describe_____________________________________
6
Check only ONE option The former student Parent or guardian
Person Interviewed
X
Relative other than parent Adult service provider Friend of the former student
Post Secondary Training and Education- Pages 5-7 This section addresses a variety of issues concerning any education or training program in which the student has been enrolled at any time since leaving high school. Question 1 concerns enrollment in any type of education or training program since high school. If the student is enrolled presently, select “Yes, currently enrolled.” If the student was enrolled in the past, select “Yes, but not currently enrolled.” If the student has not been enrolled in any type of education or training program since high school select “No.” Select only one answer. Check only ONE option
1.
Since leaving high school have you enrolled in any type of education or training program?
No Yes, currently enrolled Yes, but not currently enrolled
X
7
Question 2 involves identifying any education or training programs that the student has been enrolled in since leaving high school. The question is split into three sets of columns: Enrollment Status, Currently Enrolled, and At Least One Full Term Completed. For each kind of program in which a student is or was enrolled, indicate if his/her status was full or part time. Then indicate if the student is or is not currently enrolled. Finally, indicate if the student completed at least one full term. If the student has not been enrolled at all since high school, select the N/A box at the bottom of the question. Check ALL that apply
Locate each type of education or training program you have been enrolled in at any time since leaving high school. Select if you are/were enrolled full- or part-time. 2.
Training Program
Currently Enrolled
At least one full term completed
Yes
No
Yes
X
X
No
2 or 4 year college Postsecondary vocational training program High school completion document or certificate (Adult Basic Education, GED) Short-term education or employment training program Community or technical college
X
Apprenticeship program
Indicate if you are currently enrolled. Indicate whether or not you completed at least one full term.
Enrollment Status Full Part Time Time
On-the-job training Licensing program (Nursing, Cosmetology, etc.) Adult continuing education courses Adult Training Facility Adult center program Adult in-home program Other training program:
Select N/A if you were not enrolled in any educational or training program since high school.
Please describe:_________________
N/A
8
Question 3 lists the reasons why the student is not currently enrolled in an education or training program. Select all reasons that apply from the list if the student has never been enrolled or if the student is not currently enrolled. If the student is currently enrolled, select N/A. Check ALL that apply Did not meet prerequisites for school Employed Stay-at-home parent
3.
Why did you not enroll in an education or training program since leaving high school?
In jail or prison Unable to complete training program/dropped out of program Lack of transportation Limited funds
X
I am not interested
Select N/A if you are currently enrolled in any educational or training program.
Other: Please describe:________________________________________
N/A Question 4 lists the reasons why the student did not complete at least one term in an education or training program. Select all reasons that apply from the list if the student failed to complete at least one term. If the student completed at least one term, select N/A. Check ALL that apply Was not benefitting from the course
4.
Change in employment status
Why have you not completed at least one term in an education or training program?
Illness/medical issues In jail or prison Lack of transportation Limited funds Did not receive necessary accommodations Term is still in progress
Select N/A if you completed at least one term in any educational or training program since high school.
Other: Please describe:________________________________________
N/A
X 9
Question 5 pertains to accommodations received in a post-secondary education or training program since leaving high school. Please identify all accommodations that were received. If the student was enrolled and had no accommodations, select “None”. If the student was never enrolled, select N/A. If an item with “please describe” is selected, be sure to add clarifying information in the space provided. Check ALL that apply A note-taker Extra time on tests or assignments Books on tape Electronic textbooks read to me using a computer A tape recorder A reader Someone writing for me during test Personal care attendant Sign language interpreter
Which accommodations have you received in your education or training program(s) since high school?
X
Assistive technology:
5.
Please describe:_________________________________
If you were enrolled, but did not receive accommodations, select None
Other: Please describe:_________________________________
None Select N/A if you were not enrolled in any educational or training program since high school.
N/A
Postsecondary Employment - Pages 7-9 This section addresses a variety of issues concerning any type of employment that the student has held since leaving high school. Question 6 concerns any type of employment since leaving high school. If the student is employed presently, select “Yes, currently employed.” If the student was employed in the past since leaving high school, select “Yes, but not currently employed.” If the student has not been employed at all since high school select “No.” Select only one answer. Check only ONE option No
6.
Since leaving high school have you been employed?
X
Yes, currently employed Yes, but not currently employed
10
Question 7 involves identifying the different types of employment that the student has held since leaving high school. The question is split into two sets of columns: Employment Status and Currently Employed. For each kind of job a student has or did have, indicate if his/her status was full or part time. Also indicate if the student is or is not currently employed. If the student has not been employed at all since high school, select the N/A box at the bottom of the question. Check ALL that apply Locate each type of employment you have had at any time since leaving high school.
Employment Status Full Part Time Time
Currently Employed Yes
No
Competitive employment Military
7. Select if you are/were employed full- or parttime. Indicate if you are currently employed.
Select N/A if you were not employed at all since high school.
Employed in family business Self-employment Supported employment (paid work in a community setting with support services)
N/A X
11
Question 8 lists the reasons why the student is not currently employed. Select all reasons that apply from the list if the student has never been employed or if the student is not currently employed. If the student is currently employed, select N/A. Check ALL that apply Enrolled in a post secondary education/training program Looking for a job, but can’t find one
X
Stay-at-home parent In jail or prison
Why are you not currently employed?
Laid off Lack of transportation
8.
X
I am not interested Fear of losing benefits Other: Please describe:______________________________________
Select N/A if you are currently employed.
N/A
Questions 9, 10, and 11 ask more detailed information about the student’s most recently held job. Specifically, the student is asked to identify the average number of hours worked, the highest hourly wage earned, and the length of employment. If the student has not been employed at all since high school, select N/A for each question. Check only ONE option
9.
Since leaving high school, have you been employed for a total of at least 90 days? (The days do not have to be consecutive and could be from multiple jobs.)
Yes No
N/A X
Select N/A if you have not been employed at all since high school.
Check only ONE option On average, how many hours do/did you work in a week? (If you have more than one job, add the hours to find the total number of hours worked per week.)
1 – 19 hours per week 20 – 35 hours per week 36 – 40 hours per week
10.
41 or more hours per week
Select N/A if you have not been employed at all since high school.
N/A X 12
Check only ONE option Yes
Were you paid at least minimum wage ($7.25)?
No
11.
Choose not to answer
Select N/A if you have not been employed at all since high school.
N/A X
Question 12 pertains to accommodations received at any job since leaving high school. Please identify all accommodations that were received. If the student was employed and had no accommodations, select “None”. If the student was never employed, select N/A. Check ALL that apply Job Coach Mentor
Which accommodations have you received at your place of employment since leaving high school?
Equipment modifications Picture directions Modified schedule Personal care attendant Sign language interpreter Extra time to complete job tasks
12. If you were employed, but did not receive accommodations, select None
Assistive technology: Please describe:____________________________ Other: Please describe:____________________________
None: Select N/A if you have not been employed at all since high school
N/A X
13
Activities (Page 9) Question 13: For each activity listed, rate the student’s level of independence on the scale “Can do independently,” “Can do with assistance,” and “Dependent on others to do.” Select only one rating per activity, but be sure to rate all activities. If the student does not engage in an activity, select “N/A – Do not take part in this activity.” Give one rating to each of the following Can do Independently
Activities Housework
13.
How much help do you need with each of these activities?
Can do with assistance X
Money management
X
Personal hygiene
X
Meal planning and preparation
X
Decision-making
X X
Arranging transportation Participating in recreation/leisure activities Involvement in community organizations Voting
N/A - Do not take part in this activity
X
Making appointments
Maintaining health and fitness
Dependent on others to do
X X
X X
14
List of Students for Whom the LEA Needs to Complete a Post School Survey
Former Student Leaver’s Contact Information and Pre-populated Post-School Survey Forms
Annotated Instructions for Post School Survey Completion
IU and PaTTAN Transition Consultants’ Support Structure for PaPOS 2015-2016
Contacting Hard -to-Find Youth: Strategies for the Post-School Survey
Strategies to Contact Youth for the PaPOS Process: Lessons from Pennsylvania Schools
UPS Mailing Labels
Procedures: The following are procedures for targeted Cohort 5 LEAs to complete the Post School Survey:
Contact all former student leavers no earlier than one year after the students left school through no later than September 30, 2016 o
Former student leavers are graduates, dropouts, and students who aged out who had IEPs during the 2014-15 school year.
Make 3 unique attempts at contacting all former student leavers. It is required that these attempts be made on different days and/or utilize a variety of communication methods.
Submit completed surveys to PaTTAN Pittsburgh: o
Make a copy of the surveys for your records.
o
Return the completed original colored surveys to PaTTAN Pittsburgh based on the submission target dates indicated on the back of this form.
o
Retain your UPS tracking receipt for your records. To contact UPS for a direct pickup at your building call 1-800-PICK-UPS (742-5877). 1
If you have any questions or concerns regarding the PaPOS process for this year, please send an email to: [email protected]
Submission Target Dates DATE
MATERIAL
7/15/16
First submission of all completed Post surveys to date from Cohort 5 LEAs mailed to PaTTAN Pittsburgh via UPS.
8/15/16
Second submission of all completed Post surveys to date from Cohort 5 LEAs mailed to PaTTAN Pittsburgh via UPS. Recommendation: 50% of surveys due to PaTTAN
9/30/16
Final submission of all completed Post surveys from Cohort 5 LEAs mailed to PaTTAN Pittsburgh via UPS.
2
PENNSYLVANIA POST SCHOOL SURVEY
2015-16 – Cohort 5 Annotated Instructions The following annotated instructions correlate to the 2015-16 PaPOS Post School Survey. Please review prior to conducting the PaPOS Post School Survey with your former student leavers. Administrative Considerations The Post School Survey should be administered in an interview fashion by an individual familiar with the student being interviewed. If a student’s disability limits his/her ability to respond accurately to the survey questions, an individual (e.g., family member, provider agency staff, etc.) can assist the student in answering the student survey questions. At the conclusion of the survey, make a copy of the completed survey. Mail the original survey to PaTTAN Pittsburgh based on the schedule provided in the 2015-16 Pennsylvania Post School Outcomes Survey Timeline & Procedures document. The Timeline & Procedures document is included in your materials packet. Former Student Leaver’s Contact Information Sheet – Page 1 This information was entered last year as part of the 2014-15 PaPOS Exit Survey. It should be used to contact the former student. Contact information should have been entered for both the former student and his/her primary contact. If the contact information is incomplete or is incorrect to the extent that you cannot reach the student nor his/her primary contact, refer to the most recent student records for correct information. (The LEA is required to make every reasonable attempt to contact the former student.)
3
District: xx SD
Former Student’s Contact Information: Former Student’s Name: Jane Doe Home Phone: 2165319086 Cell Phone: 2165232899 Email Address: [email protected] Street Address: 543 MAIN ST City: VINTON State: PA Zip code: 15961
Primary Contact Information: Contact’s Name: John Doe Relationship to former student: Father Home Phone: 2165319086 Cell Phone: Email Address: Street Address: 543 MAIN ST City: VINTON State: PA Zip code: 15961
If the contact information is incorrect or is missing, refer to the student’s school records. 4
Former Student’s Demographic Information - Page 3 Demographic information was provided when the Exit survey was completed at the end of the 2014-15 school year. The information includes the former student’s LEA, last name, first name, PA Secure ID, and Date of Birth. If any of the demographic information is incorrect, please make the correction on the survey form in Red Ink.
Former Student’s Demographic Information Former Student’s LEA Former Student’s Name
Steel City SD
Jones
Bob
Last Name
First Name
Former Student’s PA Secure ID
Former Student’s Date of Birth MM/DD/YYYY
222222222
8/22/1998
Record of Attempts to Contact – Page 3 LEAs are required to make 3 unique attempts to contact each former student leaver. Attempts must be made on different days and/or utilizing a variety of communication methods (e.g., telephone calls, mailing, internet contact, etc.). Contact information provided on last year’s exit survey appears on the Student’s Contact Information Sheet (Page 1) of each former student’s PaPOS Post School Survey Form. If the information is incomplete or inaccurate to the degree that the student cannot be reached, refer to the most recent school record for the student. Contact all former leavers no earlier than one year after the student left school through no later than September 30, 2016 Record if you were able to complete the survey. If you did not successfully contact the student/contact person or if he/she refused to be interviewed, select “No”. Were you able to complete the survey?
Yes No
X 5
Select the reasons why the interview could not be completed. Check as many reasons as apply. If the survey was completed successfully, select N/A. Check ALL that apply
Why was the survey unable to be completed?
Contact information was not correct Person declined to be interviewed or did not respond to request Former student is deceased
X X
N/A Survey was completed
Record the dates when you attempted to contact the student to complete the survey. Make sure that all the dates listed occurred at least one year AFTER the student left school. On what dates did you attempt the survey? Attempt Date of Attempt 1 07/01/2016 2
07/15/2016
3
09/01/2016
If you are unable to complete the survey after 3 attempts, you have fulfilled the requirement for the Post School Survey for this former student. Complete the 3 survey questions on page 3 and submit the survey to PaTTAN Pittsburgh. Characteristics of Interviewer – page 4 This section marks the beginning of the Post Survey questions. Please begin by selecting the primary role of the interviewer and identifying the person who was interviewed. Select only one option for each item. Check only ONE option Teacher
X
Administrator Transition personnel
Primary Role of Interviewer
Paraprofessional/education assistant School psychologist School counselor Other Please describe_____________________________________
6
Check only ONE option The former student Parent or guardian
Person Interviewed
X
Relative other than parent Adult service provider Friend of the former student
Post Secondary Training and Education- Pages 5-7 This section addresses a variety of issues concerning any education or training program in which the student has been enrolled at any time since leaving high school. Question 1 concerns enrollment in any type of education or training program since high school. If the student is enrolled presently, select “Yes, currently enrolled.” If the student was enrolled in the past, select “Yes, but not currently enrolled.” If the student has not been enrolled in any type of education or training program since high school select “No.” Select only one answer. Check only ONE option
1.
Since leaving high school have you enrolled in any type of education or training program?
No Yes, currently enrolled Yes, but not currently enrolled
X
7
Question 2 involves identifying any education or training programs that the student has been enrolled in since leaving high school. The question is split into three sets of columns: Enrollment Status, Currently Enrolled, and At Least One Full Term Completed. For each kind of program in which a student is or was enrolled, indicate if his/her status was full or part time. Then indicate if the student is or is not currently enrolled. Finally, indicate if the student completed at least one full term. If the student has not been enrolled at all since high school, select the N/A box at the bottom of the question. Check ALL that apply
Locate each type of education or training program you have been enrolled in at any time since leaving high school. Select if you are/were enrolled full- or part-time. 2.
Training Program
Currently Enrolled
At least one full term completed
Yes
No
Yes
X
X
No
2 or 4 year college Postsecondary vocational training program High school completion document or certificate (Adult Basic Education, GED) Short-term education or employment training program Community or technical college
X
Apprenticeship program
Indicate if you are currently enrolled. Indicate whether or not you completed at least one full term.
Enrollment Status Full Part Time Time
On-the-job training Licensing program (Nursing, Cosmetology, etc.) Adult continuing education courses Adult Training Facility Adult center program Adult in-home program Other training program:
Select N/A if you were not enrolled in any educational or training program since high school.
Please describe:_________________
N/A
8
Question 3 lists the reasons why the student is not currently enrolled in an education or training program. Select all reasons that apply from the list if the student has never been enrolled or if the student is not currently enrolled. If the student is currently enrolled, select N/A. Check ALL that apply Did not meet prerequisites for school Employed Stay-at-home parent
3.
Why did you not enroll in an education or training program since leaving high school?
In jail or prison Unable to complete training program/dropped out of program Lack of transportation Limited funds
X
I am not interested
Select N/A if you are currently enrolled in any educational or training program.
Other: Please describe:________________________________________
N/A Question 4 lists the reasons why the student did not complete at least one term in an education or training program. Select all reasons that apply from the list if the student failed to complete at least one term. If the student completed at least one term, select N/A. Check ALL that apply Was not benefitting from the course
4.
Change in employment status
Why have you not completed at least one term in an education or training program?
Illness/medical issues In jail or prison Lack of transportation Limited funds Did not receive necessary accommodations Term is still in progress
Select N/A if you completed at least one term in any educational or training program since high school.
Other: Please describe:________________________________________
N/A
X 9
Question 5 pertains to accommodations received in a post-secondary education or training program since leaving high school. Please identify all accommodations that were received. If the student was enrolled and had no accommodations, select “None”. If the student was never enrolled, select N/A. If an item with “please describe” is selected, be sure to add clarifying information in the space provided. Check ALL that apply A note-taker Extra time on tests or assignments Books on tape Electronic textbooks read to me using a computer A tape recorder A reader Someone writing for me during test Personal care attendant Sign language interpreter
Which accommodations have you received in your education or training program(s) since high school?
X
Assistive technology:
5.
Please describe:_________________________________
If you were enrolled, but did not receive accommodations, select None
Other: Please describe:_________________________________
None Select N/A if you were not enrolled in any educational or training program since high school.
N/A
Postsecondary Employment - Pages 7-9 This section addresses a variety of issues concerning any type of employment that the student has held since leaving high school. Question 6 concerns any type of employment since leaving high school. If the student is employed presently, select “Yes, currently employed.” If the student was employed in the past since leaving high school, select “Yes, but not currently employed.” If the student has not been employed at all since high school select “No.” Select only one answer. Check only ONE option No
6.
Since leaving high school have you been employed?
X
Yes, currently employed Yes, but not currently employed
10
Question 7 involves identifying the different types of employment that the student has held since leaving high school. The question is split into two sets of columns: Employment Status and Currently Employed. For each kind of job a student has or did have, indicate if his/her status was full or part time. Also indicate if the student is or is not currently employed. If the student has not been employed at all since high school, select the N/A box at the bottom of the question. Check ALL that apply Locate each type of employment you have had at any time since leaving high school.
Employment Status Full Part Time Time
Currently Employed Yes
No
Competitive employment Military
7. Select if you are/were employed full- or parttime. Indicate if you are currently employed.
Select N/A if you were not employed at all since high school.
Employed in family business Self-employment Supported employment (paid work in a community setting with support services)
N/A X
11
Question 8 lists the reasons why the student is not currently employed. Select all reasons that apply from the list if the student has never been employed or if the student is not currently employed. If the student is currently employed, select N/A. Check ALL that apply Enrolled in a post secondary education/training program Looking for a job, but can’t find one
X
Stay-at-home parent In jail or prison
Why are you not currently employed?
Laid off Lack of transportation
8.
X
I am not interested Fear of losing benefits Other: Please describe:______________________________________
Select N/A if you are currently employed.
N/A
Questions 9, 10, and 11 ask more detailed information about the student’s most recently held job. Specifically, the student is asked to identify the average number of hours worked, the highest hourly wage earned, and the length of employment. If the student has not been employed at all since high school, select N/A for each question. Check only ONE option
9.
Since leaving high school, have you been employed for a total of at least 90 days? (The days do not have to be consecutive and could be from multiple jobs.)
Yes No
N/A X
Select N/A if you have not been employed at all since high school.
Check only ONE option On average, how many hours do/did you work in a week? (If you have more than one job, add the hours to find the total number of hours worked per week.)
1 – 19 hours per week 20 – 35 hours per week 36 – 40 hours per week
10.
41 or more hours per week
Select N/A if you have not been employed at all since high school.
N/A X 12
Check only ONE option Yes
Were you paid at least minimum wage ($7.25)?
No
11.
Choose not to answer
Select N/A if you have not been employed at all since high school.
N/A X
Question 12 pertains to accommodations received at any job since leaving high school. Please identify all accommodations that were received. If the student was employed and had no accommodations, select “None”. If the student was never employed, select N/A. Check ALL that apply Job Coach Mentor
Which accommodations have you received at your place of employment since leaving high school?
Equipment modifications Picture directions Modified schedule Personal care attendant Sign language interpreter Extra time to complete job tasks
12. If you were employed, but did not receive accommodations, select None
Assistive technology: Please describe:____________________________ Other: Please describe:____________________________
None: Select N/A if you have not been employed at all since high school
N/A X
13
Activities (Page 9) Question 13: For each activity listed, rate the student’s level of independence on the scale “Can do independently,” “Can do with assistance,” and “Dependent on others to do.” Select only one rating per activity, but be sure to rate all activities. If the student does not engage in an activity, select “N/A – Do not take part in this activity.” Give one rating to each of the following Can do Independently
Activities Housework
13.
How much help do you need with each of these activities?
Can do with assistance X
Money management
X
Personal hygiene
X
Meal planning and preparation
X
Decision-making
X X
Arranging transportation Participating in recreation/leisure activities Involvement in community organizations Voting
N/A - Do not take part in this activity
X
Making appointments
Maintaining health and fitness
Dependent on others to do
X X
X X
14
