Employment Survey

Trainee Name*

First NameLast 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*

Choose yes or no.

Guardianship is in effect for Trainee*

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):*

Receptive Communication abilities of Trainee - Difficulty understanding verbal (spoken) or non-verbal (visual) communication:*

Choose one.

Expressive Communication abilities of Trainee - Difficulty expressing oneself using verbal (spoken) or non-verbal (visual) communication system:*

Choose one.

Articulation abilities of Trainee - Difficulty speaking clearly so as to be understood by others.*

Choose one.

Non-verbal Communication System required by Trainee: (Check all that apply.)*

Assistive Tehnology used by Trainee: (Check all that apply.)*

Social Interaction: (Check all that apply.)*

Learning style: (Check all that apply.)*

Learns tasks by watching others on the jobBenefits from hand-over-hand instruction or modeling the taskNeeds visual strategies such as schedule, work system, charts, color codesJob must be broken down into small steps, and each step practiced intensivelyRequires communication system to participate in two-way conversationComplex 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 independentlyNeeds verbal or visual prompts to find required areas such as above.

Adaptive Skills: (Check all where assistance is needed.)*

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.)*

NonePhysical - wheelchair, elevator, enlarged pen, cane, hearing aidsSensory - Movement breaks, sound eliminating headphones, isolated work areaSocial - social stories, comic book stories, social autopsyOrganization - 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.

Employment Survey

Trainee must complete the following:

Parent/Caregiver must complete the following: