Transition Educational Exiting Profile/MDS Behavioral Page 8

Name / D.O.B.
Address / Parent/Guardian
Phone # / County
Diagnosed Primary Disability / Secondary Disability

EDUCATIONAL INFORMATION

Graduating School / Home District
Graduating Teacher
Date of Graduation
Type of Program

ELIGIBILITY INFORMATION

Is the individual eligible for services through the Office of Intellectual Disabilities/Developmental Delay Program (MR)? Yes No

Is the individual eligible for services through the MH system? Yes No

Did the individual apply for OVR services? Yes No

Does the individual receive SSI Benefits? Yes No

Does the individual have an ACCESS card? Yes No

Does the individual have a Social Security ID card? Yes No

Does the individual have a PA Photo ID card? Yes No

Is the individual registered to vote? Yes No

Is the individual registered for the Selective Service? Yes No

Is it a realistic goal for the individual to get a Driver’s License? Yes No

COMMUNICATION

1.  Mode of Communication

Verbal - If yes, describe type of communication (e.g. one word, utterances, complete sentences).

Explain present skills:

Non-verbal – If yes, describe type of communication (i.e. communication board, schedules, picture board, eye gaze).

Explain present skills:

What Vocal Output Communication Devices have been used successfully:

2.  Primary Language:

3.  Since behavior is also a communication mode, please list any behaviors as well as what the inferred message might be (e.g. individual will drop to the floor as a way of telling us he does not want to comply):

Other behaviors under communication:

DAILY LIVING

1.  Meals/Feeding
a.  Likes: / Dislikes:
b.  Is the individual independent in eating skills? Yes No
Opening containers
Spreading
Use of utensils fork knife spoon
Use of napkin
Clean eating area
c.  Does the individual require support with eating: Yes No
If yes, what does this support look like:
2.  Toileting
a.  Does the individual indicate? Yes No
If yes, how:
b.  Is he/she successful on the toilet? Yes No
c.  Is there a recommended schedule? Yes No
d.  Does the individual require support with toileting needs? Yes No
If yes, what does this support look like:
3.  Dressing
a.  Is the individual independent in dressing skills? Yes No
b.  Does the individual require support with dressing needs? Yes No
If yes, what does this support look like:

BEHAVIORAL CONSIDERATIONS

List all behaviors the individual exhibits:
Include strategies implemented to address behaviors:
Are any behaviors determined to be of danger to self or others? Yes No
If yes, please list those behaviors:

ASSISTIVE TECHNOLOGY/ACCESS

List any devices that enable access:
Tell how they are used:

SENSORY STRATEGIES

What techniques or equipment assists the individual to attend to the task and decrease negative behaviors:
List any items that elicit negative responses:
Does the individual require sensory breaks? Yes No
If yes, How often?

LEISURE/RECREATION/COMMUNITY-BASED ACTIVITIES

Provide a list of preferred activities:

VOCATIONAL SKILLS

Attach a job skills inventory if one has been done. Obtain information from special education personnel, job coaches, etc.

Individual’s Job Preferences/Expressed Areas of Interest:
Work Based Learning Program:
No Work Related Experiences. Explain:
Describe Strengths and Abilities in Jobs Assessed:
Work Site / Experiences
Recommendation of IEP team:
Individual’s behavior in work environment and supports needed to maintain appropriate behavior (Behavior Protocol, Reinforcer List):
Accommodations/Environmental/Sensory Considerations Needing to be Addressed:
Habits, Routines, Idiosyncrasies:
Safety Considerations: (e.g. overly friendly, unaware of danger/environment, knowing what to do in an emergency, has emergency contact list, etc.):

ENDURANCE

1.  Endurance is less than: 1 hour 1-2 hours 2-3 hours or more
2.  Can the individual work while seated for at least one hour at a time? Yes No Don’t know
3.  Can the individual work while standing for at least one hour at a time? Yes No Don’t know
4.  Must the individual alternate between sitting and standing? Yes No
5.  Individual can: lift pounds, carry pounds, push pounds
6.  List any restrictions: sit stand kneel stoop bend crawl none

TRANSPORTATION

1.  Mode of Transportation to Access Community/Work Site:
a.  Bus/Public Transportation
b.  Specialized Transportation
c.  Walk
d.  Family providing transportation
e.  Agency providing transportation
f.  Other
2.  Type of Support Needed:
a.  Independent
b.  Needs Training (i.e. Training in Pedestrian Safety, Travel Instruction, etc.)
c.  Needs Assistance

MEDICAL STATUS

Medical Condition/Disability Diagnosis:
Concerns:
Indicate seizures and protocol to be followed:
List current medications with dosage and time:
Medications / Dosage / Time

ADDITIONAL INFORMATION

Team members who participated in the completion of this profile:
Name / Role / Contact Information

This document is a result of a collaborative effort and has been modified with permission from Lehigh and Northampton Employment Coalition.
No parts of this document are to be used or reproduced without permission from Lehigh and Northampton Employment Coalition. Modified 2012

Transition Educational Exiting Profile/MDS Behavioral Page 8

AGENCIES

Indicate agencies involved in providing services (e.g. Office of Intellectual Disabilities, OVR, Nursing Agencies, etc.)
Name of Agency / Contact Name / Contact Number

PARENTAL INPUT

Please list any information that may have been overlooked which you think is pertinent to the care and programming for the individual:

This document is a result of a collaborative effort and has been modified with permission from Lehigh and Northampton Employment Coalition.
No parts of this document are to be used or reproduced without permission from Lehigh and Northampton Employment Coalition. Modified 2012