HomeMy WebLinkAboutDetermination Checklist(attachment #1c MDCPS Modified Annual Self -Determination Checklist)
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- Division of Special Education
14-21)
Miami-Oaoe County Modified Annual Self -Determination Checklist (for students ages
Public Schools
Name: ID#: Signature:
Student: Self-determination involves knowing about yourself, making decisions, setting goals, taking care of yourself, and
more. Use this checklist to rate our self-determination skills. This is not a test!
Rate yourself or rate the student by marking the box after each statement.
1= Yes, I can do this without help.
2= Sometimes I need help with this.
3= No, I need help with this.
4= I don't know.
5= This does not a. .1 to me.
About 112e
1. I can seek hell when needed.
Indicate
the elate
Date:
Age:
-
i'our
this
is completed.
Dale:
Age:
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checklist
Date:
Age:
and
Date:
Age:
2. I can follow rules at school.
3. I can follow rules at home.
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4. I can follow rules in the communi .
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5. I can talk about or show somethin: that I like to do.6.
I can describe m stren: hs and challen:es.
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7. I can ex. ress m wants and needs effectivel .
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8. I know m name.9.
I can write m name.
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10. Iknow m address.11.
I know m tele • hone number.
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12. I know m social securi number.13.
I know m student identification (ID number.14.
I know where to locate important information about me (e.g., birth certificate, social
securi card .
15. I understand how m disabili affects m life.
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16. I know what accommodation s I need.
*Plana iHH einflorvl'a f' D,.,.af .l:
07/06
Division of Special Education
>~taml-Dads Modified Annual Self -Determination Checklist (fin. students ages 14-21)
Public Schools
ii.,,.M Mir“:4.10i :fN: W4e'l
Name:. ID#: Signature:
Student: Self-determination involves knowing about yourself, making decisions, setting goals, taking care of yourself, and
more. Use this checklist to rate our self-determination skills. This is not a test!
Rate yourself or rate the student by marking the box after each statement.
1= Yes, I can do this without help.
2= Sometimes I need help with this.
3= No, I need help with this.
4= I don't know.
5= This does not as .1 to me.
AbcaL 11i ocial 7 _ige
1. I can talk on the shone with famil and friends.
Inclic•ate
the elute
Date:
Age:
-
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this
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Date: °
Age:
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Date:
Age:
Date:
Age:
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2. I can make choices.
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3. I have friends.
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4. I can walk awa when ma, .
5. I use a .ro'hate lan:ua:e when I am and .
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6. I . articisate in recreational activities.
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7. I belon: to clubs/or:anizations.
8. I can schedule a social activi with at least one friend.
9. I can interact with adults a.. ro . riatel .
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10. I reco la ize other . eo • le's feelin:s e.:., bo, lan • a: e).
11. I can give people their personal space.
12. I can engage in a conversation with others.
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13. I can give my opinion appropriately.
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14. I can disagree appropriately.
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*Db...,.....s..2 _if.. /l n__.o_r2,_
07/06
Division of Special Education
ages 14-21)
_`
Mia Modified Annual Self -Determination Checklist (for students
Public Schools
Name: ID#: Signature:
Student: Self-determination involves knowing about yourself, making decisions, setting goals, taking care of yourself, and
more. Use this checklist to rate our self-determination skills. This is not a test!
Rate yourself or rate the student by marking the box after each statement.
1= Yes, I can do this without help.
2= Sometimes I need help with this.
3= No, I need help with this.
4= I don't know.
5= This does not a. .1 to me.
About „� Career/0e"
1. I can learn from ex. eriences.
Indicate
the date
Date:
Age:
_
your
this
completecl.
Date:
Age:
-
cage
checklist
Date:
Age:
(mil
is
Date:
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2. I can identi m careerfob :oal s .
3. I can dress a.. ro . riatel for work.
4. I can develo . a resume.
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5. I can com.lete a basic al e lication.
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6. I know how to search for a job.7.
I know how to schedule a job interview.8.
I show res sect for authori fi:ures.
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9. I can sta on -task.
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10. I can perform simple steps in a job related routine.
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11. I can switch tasks when told to do so.
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12. I can answer questions about tasks that I can perform.
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13. I have a desire to work.
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14. I can make helpful decisions in the workplace.
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15. I can explain my disability to others.
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16. I can set an alarm clock to wake me ue on time.
*A]nno ; , ot:.4.t. 0n /' D..-•! 1...
07/06
Division of Special Education
ages 14-21)
Moom� WOa County Modified Annual Self -Determination Checklist (for students
Public Schools
Name: ID#: Signature:
Student: Self-determination involves knowing about yourself, making decisions, setting goals, taking care of yourself, and
more. Use this checklist to rate our self-determination skills. This is not a test!
Rate yourself or rate the student by marking the box after each statement.
1= Yes, I can do this without help.
2= Sometimes I need help with this.
3= No, I need help with this.
4= I don't know.
5= This does not as .l to me.
About I'j Education
1. I can make chan:e.
1j!clicOte
the elute
Dale:
Age:
-
your
this
completed.
Date:
Age:
-
age
checklist
Date:
Age:
-
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i.s
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Age:
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2. I can count coins.3.
I can count bills.
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4. I can tell time.5.
I can :o from class to class b m self.
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6. I can follow a schedule.
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7. I . artici . ate in m Individual Educational Plan IEP meetin_ s.
8. I can follow verbal directions.
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9. I can follow written directions.
10. I can use technolo: /assistive technolo 3 to . erform tasks.
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11. I show interest in learnin: new thin:s.
12. I can talk about/demonstrate what I learned.
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13. I can use . ictures to hels me read and understand.
14. I can locate information from different sources.
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15. I can work in a : ous takin: turns.
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*Plnro in cffiebiaflc !' D.... ' 1.,.
07/06
Division of Special Education
Miaml-Qede County Modified Annual Self -Determination Checklist (forsttents aces 14-21
Publac Schools td.. )
-'s our;.,,:-e.«„;,.a• .......:,, b
Name: ID#: Signature:
Student: Self-determination involves knowing about yourself, making decisions, setting goals, taking care of yourself, and
more. Use this checklist to rate our self-determination skills. This is not a test!
Rate yourself or rate the student by marking the box after each statement.
1= Yes, I can do this without help.
2= Sometimes I need help with this.
3= No, I need help with this.
4= I don't know.
5= This does not a. el to me.
About 112s. tcti4T lavit s Skill5
1. I can .re.are simile meals.
Indicate
the date
Date:
Fiji
_---
your
this
coinpleted.
Date:
Age:
ctge
checklist
Date:
Age:
cruel
is
Date:
Age:
2. I know how to use kitchen a..liances e.:., stove, oven, microwave, washin: machine .3.
I can . erform household chores e.:., wash dishes, make bed, clean room, take out trash .
4. I can recognize street signs by color and shape.
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5. I can recognize store signs and common logos.
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6. I can recognize poison symbols and other warning signs.
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7. I can make a shopping list for my personal needs.
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8. I know where to buy products for my personal needs.
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9. I know how to make a de . osit and withdrawal at the bank.
10. I can use the restroom inde. endentl .
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11. Ican feed m self.12.
I know my travel options.
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13. I maintain good personal grooming/hygiene.
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14. I can schedule my appointments (e.g., doctor, interview).
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15. I can identify my prescribed medications.
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16. I can take care of my medical/health needs.
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*Dlnnn i....f.,,I,...fa.. !' 13....i417?..
07/06