Student Academic Transition Survey

1

Mr. Charles F. Mahoney
Executive Director / Fayette-Greene-Washington
INTERMEDIATE UNIT 1One Intermediate Unit Drive
Coal Center, PA 15423-9642
Telephone 724-938-3241 Fax 724-938-8722

Student Academic Transition Survey

Student’s Name: Date of Birth: ______

Expected Year of Graduation: ______

Date of Original Survey:

School District: Grade:

Date Updated:

School District: Grade:

Date Updated:

School District: Grade:

Secondary Academic Transition Survey

Student Form

Please complete this future-planning document for your upcoming IEP conference.

General Student Information

Your Name:
First / Middle / Last
Person Living With: / Birth Date:
Anticipated Graduation Date: / Grade:
Current Address: / Phone Number:
Parent’s Name: / Cell Phone:

1. Vocational/Post-Secondary Education Options

1. Upon graduation, what do you see yourself doing for future education or training? (Check all that apply)

Four-Year College/University / Occupational Training Program (Eligibility Requirements)
Community College / Military Service
Technical College / Community Education Program

What will you be studying or training to be?

What is your level of motivation to succeed in the academic setting?

High Medium Low

What is your level of control over decision-making and your individual success?

High Medium Low

What is your ability to identify what you needs and how to get it?

High Medium Low

1. Upon graduation, in what kind of employment setting do you see yourself?

Competitive Employment: Full-Time Part-Time

Self-Employed: Full-Time Part-Time

Supported Employment: Full-Time Part-Time

1. What type of job/occupation do you see yourself working in one year after graduation?

1. What work-related demands are being placed on you at home, and what is your reaction to them?

Activity / Degree of Independence
For example, makes beds, carries out trash mows lawn. / Does Independently / Needs Guidance / Unwilling to Perform Task
1)
2)
3)
4)
5)

1. List any jobs or chores you do now and enjoy.

1. What jobs or work experience have you had?

1. List any jobs you really dislike.

1. Home Living Options

1. Where do you think you will most likely live after graduation?

What City or Town?

1. (Please check one from this list.)

Live independently in apartment or home.

With family member (who?)

College dormitory (where?)

Other, please describe.

1. Recreational and Leisure Options

1. Leisure Interest Inventory

Check all of the following leisure activities you do during your free time:

Participate in Athletic/Sports Activities:

Swimming / Lifting Weights / Skiing
Running / Aerobics / Riding Motorcycle
Softball / Basketball / Canoeing
Walking / Fishing / Camping
Riding Bike / Bowling / Riding Horses
Other:

Attend Large Group Events:

Movies / Car Races
Ball Games / Horse, Dog, Car Shows
Music Events / Community Education Classes
Other:

Participate in Individual Activities:

Sewing / Listen to Music / Shopping
Handcrafts / Cooking / Playing Pool/Billiards
Reading / Playing Instrument / Caring for Lawn
Caring for Pets / Writing Letters / Playing Video/Arcade Games
Talking on Phone / Watching TV / Playing Cards or Board Games
Clean/Repair Car / Other:

Participate in Social Activities:

Dating / Entertaining at Home / Attending Church
Picnicking / Volunteering / Belonging to a Social Club
Eating Out / Driving Around / Spending Time with Family or Friends
Dancing / Other:

1. Transportation Options:

A. How will you get around the community and to work?

Do Now / Need to Learn
Drive Own Vehicle
Drive Family Vehicle
Use Public Transportation
Take Taxi
Ride Bicycle
Walk
Depend on Others
Other:

1. Financial Support:

1. Do you need financial assistance in any of the following areas to reach your long-range goals?

1. Post-Secondary Education Yes No

If yes, check all of the following for which you would like information.

Office of Vocational Rehabilitation (OVR)

Pell Grants

Scholarships

Work Study

Student Loans

Supplemental Security Income (SSI)

Social Security Disability Insurance (SSDI) (i.e., PASS)

Pennsylvania Higher Education Assistance Agency (PHEAA)

1. Employment Assistance Yes No

If yes, check all of the following for which you would like information.

Office of Vocational Rehabilitation (OVR)

Supplemental Security Income (SSI)

County Social Services (MH)

Office of Developmental Programs (MR)

1. Home Living Assistance Yes No

If yes, check all of the following for which you would like information.

County Social Services

Supplemental Security Income (SSI)/Medical Assistance

Housing Assistance

1. Which of the following agencies have you contacted with regard to financial support?

Not Applicable

Office of Vocational Rehabilitation (OVR)

Social Security Office

County Social Services (MH/MR)

Other, please describe

1. Health-Related Needs:

1. Do you currently have any of the following needs?

Medical (i.e., medications) Yes* No

Counseling Yes* No

Other

*Please Explain:

1. What are some possible supports you may require in the future?

VII. Currently, what is your greatest concern about the future?

Intermediate Unit 1 does not discriminate on the basis of race, color, national origin, sex, disability, age, religion, ancestry or any other legally protected classification in its educational programs, activities or employment practices

1/11/10