Spreadsheet: 190863d1351813947-check-box-to-change-background-color-when-checked-mrjinx007-conditional-formatting-of-answers-new-assessment-7-26-12-1
Sheet: Sheet1

Consumer name:
Evaluator (print): |  |  |  |  |  |  |  | Signature:
N/A= Not applicable                  DNK= Don't know           Yes= Independent        No= Not independent
 |  | Code: HH. Health & Hygiene
 |  |  |  | This section of the assessment identifies every aspect of Health
N/A | DNK | YES | NO | and [NAME] in six categories:
 |  |  |  | A. Toileting
 |  |  |  | B. Showering/Bathing
 |  |  |  | [NAME]
 |  |  |  | D. Dressing
 |  |  |  | E. Exercise
 |  |  |  | [NAME]
 |  | Code: HL. Home Living Skills
N/A | DNK | YES | NO | This section of the assessment identifies various aspects of home
 |  |  |  | living in the following categories:
 |  |  |  | A. Living Room
 |  |  |  | [NAME] (Cooking)
 |  |  |  | [NAME] (Cleaning)
 |  |  |  | [NAME]
 |  |  |  | E. Bath And Utility Room
 |  |  |  | F. Travel Skills
 |  |  |  | [NAME]
 |  |  |  | [NAME]
 |  |  |  | I. Temperature setting
 |  | Code: C. Communication
N/A | DNK | YES | NO | This section of the assessment identifies various aspects of
 |  |  |  | communication and speech in two categories:
 |  |  |  | A. Verbal Communication
 |  |  |  | [NAME]
 |  | Code:PV. Prevocational
N/A | DNK | YES | NO | This section of the assessment identifies various aspects of
 |  |  |  | Prevocational skills in ten categories:
 |  |  |  | [NAME]
 |  |  |  | B. Ethics
 |  |  |  | C. Quality
 |  |  |  | D. Time Management
 |  |  |  | E. Dispute Resolution
 |  |  |  | [NAME] interactions
 |  |  |  | G. Self management
 |  |  |  | H. Job application skills
 |  |  |  | I. Computer skills
 |  |  |  | [NAME] skills
 |  | Code: PS. Personal & Social Setting Adjustment
N/A | DNK | YES | NO | This section of the assessment identifies various aspects of
 |  |  |  | personal and social interactions with others in nine categories:
 |  |  |  | A. Verbal skills
 |  |  |  | B. Paraverbal skills
 |  |  |  | [NAME] verbal skills
 |  |  |  | D. Emotional skills
 |  |  |  | E. Identifies own personality
 |  |  |  | F. Listening skills
 |  |  |  | [NAME] skills
 |  |  |  | [NAME] attire skills
 |  |  |  | I. Participation preferences
 |  | Code: [NAME] skills
 |  | This section of the assessment identifies various aspect of community
 |  | survival skills in ten categories:
N/A | DNK | YES | NO
 |  |  |  | A. Identifies various natural disasters
 |  |  |  | B. Identifies natural disaster procedures
 |  |  |  | C. Identifies man-made disasters
 |  |  |  | D. Follows man-made disaster instructions
 |  |  |  | E. Participates in disaster drills
 |  |  |  | F. Identifies emergency situations
 |  |  |  | [NAME] between various emergencies
 |  |  |  | H. Utilize communication device to make emergency contacts
 |  |  |  | I . Community signs and landmarks
 |  |  |  | J . Personal information
 |  | Code: SX. Sexuality
 |  | This section of the assessment identifies various aspect of
 |  | sexuality in nine categories:
N/A | DNK | YES | NO
 |  |  |  | A. Identifies various aspects of sexuality
 |  |  |  | B. Knows sexual preference
 |  |  |  | [NAME] relationships
 |  |  |  | D. Is or has been sexually active
 |  |  |  | E. Sexual vocabulary
 |  |  |  | F. States aspects of sexual anatomy and physiology
 |  |  |  | G. Identifies consequences of unprotected sex
 |  |  |  | H. Deals with sexual impulse
 |  |  |  | I. Identifies the process of sexual reproduction
 |  | Code: HS. Home Safety
 |  | This section of the assessment identifies various aspect of home
 |  | safety skills in nine categories:
N/A | DNK | YES | NO
 |  |  |  | A. Distinguish between different electrical outlets
 |  |  |  | B. Identifies the function of fuse box
 |  |  |  | [NAME] to answer door
 |  |  |  | [NAME] and secures environment
 |  |  |  | [NAME] safety
 |  |  |  | F. Emergency numbers
 |  |  |  | [NAME] state of emergency
 |  |  |  | [NAME] to evacuate
 |  |  |  | [NAME] natural disaster area
 |  | Code: CR. Community Resources
 |  | This section of the assessment identifies various aspect of
 |  | community resources in ten categories:
N/A | DNK | YES | NO
 |  |  |  | A. Medical resources/ Health Department
 |  |  |  | B. Emergency medical resources
 |  |  |  | C. Social services resources
 |  |  |  | D. Police emergency services
 |  |  |  | E. Utilities emergency services
 |  |  |  | [NAME] services
 |  |  |  | G. Community access resources [NAME]
 |  |  |  | H. Transportation resources
 |  |  |  | I. Accessing community
 |  |  |  | J. Recreational resources
 |  | Code: M. Mobility
 |  | This section of the assessment identifies various aspect of mobility
 |  | in four categories:
N/A | DNK | YES | NO
 |  |  |  | A. Public transportation choices
 |  |  |  | [NAME] choices
 |  |  |  | C. Private vehicle
 |  |  |  | [NAME] access
 |  | Code: LT. Leisure Time
 |  | This section of the assessment identifies various aspect of leisure
 |  | time in six categories:
N/A | DNK | YES | NO
 |  |  |  | [NAME] planning
 |  |  |  | B. Indoor leisure activities
 |  |  |  | C. Outdoor leisure activities
 |  |  |  | D. Hobbies
 |  |  |  | E. Computer skills
 |  |  |  | F. Senior oriented activities
 |  | Code: MM. Money Management
 |  | This section of the assessment identifies various aspect of money management
 |  | time in five categories:
N/A | DNK | YES | NO
 |  |  |  | A. Coin and bills recognition
 |  |  |  | [NAME]/pay bills
 |  |  |  | C. Bank accounts
 |  |  |  | D. Purchasing
 |  |  |  | E. Money smart
 |  | Code: RR. Reading and [NAME]
 |  | This section of the assessment identifies various aspect of reading
 |  | and writing in seven categories:
N/A | DNK | YES | NO
 |  |  |  | A. Basic reading and comprehension
 |  |  |  | B. Intermediate reading and comprehension
 |  |  |  | [NAME] reading and comprehension
 |  |  |  | D. Basic writing
 |  |  |  | E. Intermediate writing
 |  |  |  | [NAME] writing
 |  |  |  | [NAME]
 |  | Code: TM. Time Management
 |  | This section of the assessment identifies various aspect of time
 |  | management in six categories:
N/A | DNK | YES | NO
 |  |  |  | [NAME] time
 |  |  |  | B. Uses association to tell approximate time
 |  |  |  | [NAME] a routine for time management
 |  |  |  | D. Identifies seasonal and calendar events
 |  |  |  | [NAME] daily events
 |  |  |  | [NAME] clock
 |  | Code: A. Arithmetic
 |  | This section of the assessment identifies various aspect of
 |  | arithmetic issues in twelve categories:
N/A | DNK | YES | NO
 |  |  |  | A. Count from 1-100
 |  |  |  | B. Count by 5's to 100
 |  |  |  | C. Count by 10's to 100
 |  |  |  | D. Add digits
 |  |  |  | E. Subtract digits
 |  |  |  | F. Multiply digits
 |  |  |  | [NAME] digits
 |  |  |  | H. A-G: Uses calculator
 |  |  |  | I. Measures in inches
 |  |  |  | [NAME] in feet
 |  |  |  | K.Measures in yard
 |  |  |  | [NAME] in centimeter
 |  | Code: SM. Sensorimotor
 |  | This section of the assessment identifies various aspects of
 |  | sensorimotor issues in thirteen categories:
N/A | DNK | YES | NO
 |  |  |  | A. Roll a basketball size
 |  |  |  | [NAME] a basketball size
 |  |  |  | [NAME] a ball to others
 |  |  |  | D. Close a door
 |  |  |  | E. Open a door
 |  |  |  | F. Pedal a tricycle or bike with training wheels
 |  |  |  | G. Pedal a two wheeled bike
 |  |  |  | H. Exercise in a group
 |  |  |  | [NAME] beads
 |  |  |  | [NAME] a string through a card
 |  |  |  | K. Go up and down stairs
 |  |  |  | L. Use scissors
 |  |  |  | M. Use a seat belt
 |  | Code: B. Behavioral
 |  | This section of the assessment identifies various aspect of
 |  | behavioral issues in eleven categories:
N/A | DNK | YES | NO
 |  |  |  | [NAME]
 |  |  |  | B. Runs/Hides
 |  |  |  | [NAME]
 |  |  |  | D. Oppositional
 |  |  |  | E. Verbal abuse
 |  |  |  | F. Questions authority
 |  |  |  | G. Verbal Rage
 |  |  |  | H. Intimidation
 |  |  |  | I. Property destruction
 |  |  |  | J. Physical aggression
 |  |  |  | K. Autism spectrum (ASD)
 |  | Code: SAM. Self-Administration of Medication
N/A | DNK | YES | NO
 |  |  |  | A.  Self-administration
 |  |  |  | B.  Self-administration Pillbox
Health and hygiene/ |  |  | Home living/ |  | Communication/ |  | Prevocational/ |  | Personal & Social/ |  |  | Survival/
Sexuality/ |  |  | Home safety/ |  | Community resources/ |  |  | Leisure time/ |  | Money management/
Reading and writing/ |  |  |  | Time management/ |  | Arithmetic/ |  | sensorimotor/ |  | Behavioral/ |  | SAM/ | Mobility/