ASD Affinity Program - Hench Autism Studies

Your name: *

Applicant's name: *

Relationship to the Applicant: *

Will the applicant be under guardianship or a conservatorship as an adult (18 years old or older)? *

Please complete this questionnaire by selecting the performance level (PL) that you think best describes the applicant’s current skill level and ability for each of the items. We will use this information to learn more about the applicant as an individual.

PL-0 No Participation: You refuse to participate in the learning opportunity. This means that you choose not to try to do an activity.

PL-1 Early Instruction: You need prompts for most, or every, step in the task. This means that you need direct 1:1 assistance to complete the task. This means that you need someone to help you with every step of the activity.

PL-2 Guided Practice: You need specific prompts (e.g., verbal, written, gestural) to complete the task, but you do not need prompting for each step in the sequence. This means that you need help with the activity, but that you can do some parts of it on your own.

PL-3 Guided Independence: You need general prompts to complete the task (e.g., a reminder that it is an expectation to complete the task) or you complete the task within the structure of a program (e.g., because that is part of your routine at school). This means that when someone reminds you to do the activity or if it is a part of your routine you do it without any other help.

PL-4 Independent: You do not require additional instructions, prompting, or other assistance to complete the task. You independently seek resources as needed. This means that you do this activity without anyone reminding you or putting it in your schedule.

N/A: You have never had the opportunity to try this. This means that you have never been able to try the activity.

Making a simple meal. Examples of simple meals are things like canned soup, a sandwich, frozen pizza, or a salad. *

PL-0

PL-1

PL-2

PL-3

PL-4

N/A

Doing laundry. *

PL-0

PL-1

PL-2

PL-3

PL-4

N/A

Waking up on time and getting ready for the day. *

PL-0

PL-1

PL-2

PL-3

PL-4

N/A

General upkeep of living space. General upkeep includes washing dishes, wiping down counters, vacuuming, mopping, cleaning the bathroom, and taking out the garbage. *

PL-0

PL-1

PL-2

PL-3

PL-4

N/A

Organizing their living space so they can easily find things. *

PL-0

PL-1

PL-2

PL-3

PL-4

N/A

Managing their time to balance non-preferred and preferred tasks. For example, ensuring that they turn their xbox off by 8:00 pm so they can study for an upcoming exam. *

PL-0

PL-1

PL-2

PL-3

PL-4

N/A

Maintaining good personal hygiene. Examples of good personal hygiene practices are brushing their teeth daily, showering regularly, washing their hands after using the bathroom, and wearing clean clothes. *

PL-0

PL-1

PL-2

PL-3

PL-4

N/A

Scheduling medical and mental appointments. Examples of medical appointments are check-ups with the doctor, dentist appointments, or an appointment with their psychologist/psychiatrist. *

PL-0

PL-1

PL-2

PL-3

PL-4

N/A

Attending medical and mental health appointments. *

PL-0

PL-1

PL-2

PL-3

PL-4

N/A

Treating minor injuries at home. Examples of treating minor injuries include scrapes, first degree burns, splinters, and insect bites. *

PL-0

PL-1

PL-2

PL-3

PL-4

N/A

Identifying and taking appropriate over the counter medications for minor ailments. Examples of minor ailments include headache, congestion, and heartburn. *

PL-0

PL-1

PL-2

PL-3

PL-4

N/A

Taking regular medications. Regular medications are medications that they take every day. *

PL-0

PL-1

PL-2

PL-3

PL-4

N/A

Asking peers for clarification when they are unsure what their peers mean. *

PL-0

PL-1

PL-2

PL-3

PL-4

N/A

Asking authority figures for clarification or help when they don’t understand something. Examples of authority figures are professors and supervisors. *

PL-0

PL-1

PL-2

PL-3

PL-4

N/A

Asking people in the community, who they don’t know, for assistance. Examples of people in the community are servers at restaurants and cashiers at the store. *

PL-0

PL-1

PL-2

PL-3

PL-4

N/A

Using Technology to connect with classmates and friends. Examples would be texting, twitter, and instagram. *

PL-0

PL-1

PL-2

PL-3

PL-4

N/A

Telling a peer that something is bothering them without becoming verbally or physically aggressive. *

PL-0

PL-1

PL-2

PL-3

PL-4

N/A

Advocating for themselves if a need is not being met or if they need assistance. *

PL-0

PL-1

PL-2

PL-3

PL-4

N/A

Finding resources in the community by using the internet. *

PL-0

PL-1

PL-2

PL-3

PL-4

N/A

Understanding who to share personal information with and who not to. *

PL-0

PL-1

PL-2

PL-3

PL-4

N/A

Accepting feedback or correction from others in an appropriate way. *

PL-0

PL-1

PL-2

PL-3

PL-4

N/A

After completing the performance level checklist please use the space below to provide any additional information that you think is relevant for us to know about the applicant. *

Hench Autism Studies Program - Parent/Support Person Application

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