PERSONAL SUPPORT INVENTORY To be filled out by: Parent/Family/Guardian/Support person Instructions: Please use the following scale to represent level of functioning in each section. Be honest and accurate based on the skill level at this time. (3) Student is independent (2) Student requires some/moderate support (1) Student requires complete support Where necessary, write notes to explain scaled responses EATING AND FOOD PREPARATION Preparing meals and snacks: Gathers ingredients and equipment Opens containers Follows recipe Uses microwave Uses top Uses oven Current Level of Functioning 3 2 1 Eating meal Oral motor skills i.e., chewing/swallowing Uses utensils Uses manners Current of Functioning 3 2 1 Preparing eating area Sets table Gets condiments Current Level of Functioning 3 2 1 Cleaning up after meal Puts away leftovers Wipes off work surface Washes dishes Hand washing Using Dishwasher Current of Functioning 3 2 1 Accessibility to kitchen Uses adaptive equipment Current Level of Functioning 3 2 1 Skills We Should All Focus on Most: GROOMING AND DRESSING Grooming: Brushes teeth Uses mouthwash Brushes/combs hair Styles hair Skin care Uses make-up Cleans eyeglasses Current Level of Functioning 3 2 1
Cleans hearing aid ear molds Maintains appearance Dressing/Undressing Dresses and Undresses self Chooses appropriate clothes Dresses appropriately for season/weather conditions Current Level of Functioning 3 2 1 Skills We Should All Focus on Most: HYGIENE AND TOILETING Using private & public toilets toileting needs washes hands Bath / showering Shampooing / rinsing hair Managing menstrual care Shaving Men Women deodorant Current Level of Functioning 3 2 1 Skills We Should All Focus on Most: SEXUALITY, HEALTH, SAFETY Awareness of sexuality issues Awareness of public vs. private activities Closes door for bathing, toileting, dressing, etc. Appropriate show of affection Appropriate control of sexual needs Awareness of bodily and sexual functions Awareness of social media risks Knowledge and use of birth control methods Knowledge of sexually transmitted disease Current Level of Functioning 3 2 1 Knowledge of general health concerns Disease transmission (i.e., covers mouth when sneezing/coughing, controls drooling, blows nose, etc.) Health concerns specific to disability (i.e., skin care, range of motion, positioning of weight) Manages medication (i.e., knows medication schedule, ability to swallow, related behavioral concerns) Cares for minor injury and/ or illness Current Level of Functioning 3 2 1 Awareness of home hazards and emergency Current Level of Functioning
procedures Uses adaptive strategies Poisons Fire Accidents 3 2 1 Skills We Should All Focus on Most: HOUSEHOLD MAINTENANCE Keeping room neat Makes bed Changes bed linens Straightens room Current Level of Functioning 3 2 1 Handling of household chores Does laundry Vacuums / dusts Cleans bathroom Sweeps Current of Functioning 3 2 1 Maintaining outdoors Rakes leaves Mows lawn Weeds Waters lawn and plants Cleans up after animals Current Level of Functioning 3 2 1 Skills We Should All Focus on Most: TRAVEL Walking (Wheeling) to and from destination safety when crossing streets arrives at destination Current Level of Functioning 3 2 1 Riding School/City Bus demonstrates appropriate behavior when on the bus communicates with bus driver can find appropriate bus can read bus map can make a transfer knows how to pay shows bus pass Current Level of Functioning 3 2 1 Driving Own Vehicle knows laws uses seat belts knows what to do in an emergency uses appropriate adaptive equipment demonstrates safe & defensive technique Current of Functioning 3 2 1 Orienting Skills identifies signs carries identification Current Level of Functioning 3 2 1
asks for help responsible for possessions uses cautions with strangers reads maps Skills We Should All Focus on Most: GENERAL SHOPPING Handling Money/Budgeting makes shopping lists knows budget constraints handles money exchanges Current Level of Functioning 3 2 1 Locating/Getting Items pushes cart uses store directory asks for help follows list makes appropriate choices does cost comparisons Current Level of Functioning 3 2 1 Clothes/Personal Items selects appropriate store asks for help selects items within budget knows sizes makes wise choices handles exchange Current of Functioning 3 2 1 Restaurant "reads" Menu (or alternative) communicates to Waitperson uses Manners locates Restrooms tallies bill (including tip) handles money exchanges Current Level of Functioning 3 2 1 Skills We Should All on Most: USING SERVICES Using Services uses Relay system (if hearing impaired uses Beauty parlor makes Appointments uses Banking Services uses/Communicates with dentist, doctor, etc. uses Laundry/drycleaner Current Level of Functioning 3 2 1 Skills We Should All Focus on Most:
PLANNING/SCHEDULING Following daily routines shows up on time gets to where they are supposed to be adapts to changes in routine able to tell time Current Level of Functioning 3 2 1 Scheduling weekly activities uses a time management system (e.g., calendar/day planner- paper or electronic) maps out plans and time (i.e., organizes time) Current of Functioning 3 2 1 Preparing for special outings arranges special things to do handles logistics involved in planning an event Current Level of Functioning 3 2 1 Handling Time Management plans homework time arranges area attends to homework time for chores, meetings, leisure time arranges transportation Time spent on social media (e.g., facebook, instagram, snapchat) Current Level of Functioning 3 2 1 Skills We Should All on Most: SOCIAL SKILLS Telephone Use phone etiquette takes message dials phone can use phone for emergency can use assistive devices if necessary can use phone directory Current Level of Functioning 3 2 1 Caring for Others pet care sibling care babysitting elderly Current Level of Functioning 3 2 1 Reciprocal Relationships gift giving remembers birthdays sends thank you card Current Level of Functioning 3 2 1 Behavior Management Social Skills introduces self follows instructions accepts criticism or consequence accepts no for an answer greets people gets peoples attention appropriately makes requests appropriately Current Level of Functioning 3 2 1