Employment Survey
I am a
*
Trainee
Parent/Caregiver
Trainee must complete the following:
Trainee Name
*
First Name
Last Name
Trainee Preferred Name
If different from given name. For example, Katie rather than Katharine.
Trainee Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Trainee Home Phone Number
-
Area Code
Phone Number
Trainee Cell Phone Number
*
-
Area Code
Phone Number
Trainee Email
*
example@example.com
Trainee Date of Birth
-
Month
-
Day
Year
My strengths, abilities and interests:
*
For example, hard worker, likes animals
My ideal job would be:
*
I need help with the following: (Check all that apply.)
*
How to fill out a job application
Writing my resume
Learning how to interview for a job
Learning how to count money and make change
Learning how to run a cash register
I am interested in the following: (Check all that apply.)
*
Full-time work or volunteer position (40 hours)
Part-time work or volunteer position (less than 40 hours)
Working indoors
Working outdoors
Working with the public
Check all that apply.
*
I am friendly and polite.
I am neat and organized.
I like talking to people.
I know how to use a computer.
I know how to use a cash register.
I know how to add, subtract, multiply and divide.
I live
*
Alone
With Family
With Roommates
In a group home
Choose one
How will you get to work? (choose one)
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Drive my own car
Take the bus
Use Uber or Lyft and make my own pickup arrangements
Walk
Ride my bike
My parent/caregiver drives me
How far are you willing to travel to work? (choose one)
*
Less than 10 miles
10 to 20 miles
More than 20 miles
How may days per week are you willing to work? (choose one)
*
1
2
3
4
5
6
7
How may days per day are you willing to work? (choose one)
*
1
2
3
4
5
6
7
8
Check all that apply.
*
I am willing to work weekends.
I am willing to work evenings.
I am willing to work holidays.
Name and phone number of person who will be driving you to work, if applicable. Otherwise, write "none".
*
John Doe/(555) 555-5555
I am physically able to do the following: (Check all that apply.)
*
Walk or stand for long periods of time
Stoop, kneel, and bend
Lift up to 25 pounds
Check all that apply.
*
I have my High School Diploma, GED, or Certificate of Completion.
I am currently enrolled in the 10th, 11th, 12th grade or a post secondary program.
I have a State ID or passport and my Social Security Card
Please contact 248-556-5341 with questions.
Back
Next
Parent/Caregiver must complete the following:
Trainee Name
*
First Name
Last Name
1st Emergency Contact/Relationship/Phone Number
*
John Doe/Parent/(555) 555-5555
2nd Emergency Contact/Relationship/Phone Number
*
John Doe/Parent/(555) 555-5555
Power of Attorney (POA) is in effect for Trainee
*
Yes
No
Choose yes or no.
Guardianship is in effect for Trainee
*
Yes
No
Choose yes or no.
If trainee has POA and/or Guardian, enter their name(s)/phone(s). Otherwise, write "none"
*
John Doe/POA/(555) 555-5555
Medical/DSM-5 diagnosis
*
For example, Down syndrome
Medical issues/allergies including seasonal
*
For example, celiac disease, penicilin
Medications and dosages
*
List all medications the Trainee is taking and dosages
Overall Level of Support (choose one):
*
High
Medium
Low
None
Receptive Communication abilities of Trainee - Difficulty understanding verbal (spoken) or non-verbal (visual) communication:
*
No concerns
Mild
Moderate
Severe
Choose one.
Expressive Communication abilities of Trainee - Difficulty expressing oneself using verbal (spoken) or non-verbal (visual) communication system:
*
No concerns
Mild
Moderate
Severe
Choose one.
Articulation abilities of Trainee - Difficulty speaking clearly so as to be understood by others.
*
No concerns
Mild
Moderate
Severe
Choose one.
Non-verbal Communication System required by Trainee: (Check all that apply.)
*
None
Objects
Photographs
Sign language/gestures
Line drawings
Written
Graphics
Augmentative/electronic device
Assistive Tehnology used by Trainee: (Check all that apply.)
*
None
Trainee has cell phone and can use it to make and receive calls.
Cell phone for support
iPad/tablet
iPod
Braille/vision
Listening/deaf
Social Interaction: (Check all that apply.)
*
Prefers to work alone or away from co-workers.
Works well in a group/team
Benefits from positive reinforcement
Accepts constructive criticism
Requires communication system to participate in two-way conversation
Does not understand how their actions or words affect others
Needs direct instruction including practice of social rules required at work site (May need visual support tool as reminder)
Needs direct instruction about social boundaries with co-workers outside of work (May need visual support tool as reminder)
Shares equipment, materials, work space
Other
Learning style: (Check all that apply.)
*
Learns tasks by watching others on the job
Benefits from hand-over-hand instruction or modeling the task
Needs visual strategies such as schedule, work system, charts, color codes
Job must be broken down into small steps, and each step practiced intensively
Requires communication system to participate in two-way conversation
Complex instructions require extended learning time frame to master a task
Navigation within work location: (Check one.)
*
Finds work station, other required work areas, and break area independently
Needs verbal or visual prompts to find required areas such as above.
Adaptive Skills: (Check all where assistance is needed.)
*
None
Accomplishing personal needs on the job, toileting
Making decisions, reasoning, judgment
Initiating tasks
Using money, debit cards
Sustaining attention to stay on task
Preventing injury
Preventing wandering
If any of the above are checked, what support is needed? If no supports are needed, please write "none".
*
Suggested accomodations or strategies: (Check all that apply.)
*
None
Physical - wheelchair, elevator, enlarged pen, cane, hearing aids
Sensory - Movement breaks, sound eliminating headphones, isolated work area
Social - social stories, comic book stories, social autopsy
Organization - calendar, daily schedule, visual coding, checklists, work system
If any of the above are checked, please describe. Otherwise, write "none".
*
Please describe Trainee strengths, abilities, special interests, preferences, and restrictions not previously mentioned.
*
Please contact 248-556-5341 with questions.
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