Training Module Forms

Committee Contact Sheet

 

Name

 Position/Title

Organization and Address

Telephone

Fax

Email

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sample Purpose Statement

The purpose of this committee is to conduct a needs assessment of the educational services currently received by students 17-21 with significant disabilities in our school system to determine if changes are needed. We plan to assess students' educational settings, instructional supports, inclusive opportunities, employment experiences, recreation opportunities, adult agency eligibility, and ability to travel independently. Once completed, the data from this assessment will be compiled and reviewed to determine the areas in which changes would improve the services currently provided to students with significant disabilities.

 

 
 

Participating Schools and Students Form

Text Box: List below the high schools in your system that currently service student's ages 17 or older with significant disabilities and the approximate number of students served at each school. Sending High Schools Number of Students Served w/ Significant Disabilities (Age 17 or older) Comments:


Sample Students Services Needs Assessment Form

 

Name of School:   Wilson High School                                                                                                           School Year: 2002-2003__

 

 

Number of students who will receive special education services until they are 21 who are/have:

1

2

3

4

5

6

7

8

9

10

Age

Receive SSI/

SSDI

 

SSI/

SSDI

Eligible

VR

Eligible

DD/MR

Eligible

Included in general education

classes

Not included in general education classes

Received behavior support

Paid work

Unpaid work

training

Extra curricular activities  in school

Extra curricular activities  outside of school

Received travel training

Required 1:1

21= 2

 

 

 

2

 

2

0

0

2

1

1

1

0

0

1

1

20= 1

 

 

 

1

 

0

0

0

1

0

0

1

0

0

1

0

19= 4

2

2

2

1

0

4

1

2

1

0

0

1

1

18= 2

 

 

1

1

1

1

1

1

0

0

2

0

0

0

0

17= 3

 

 

 

3

2

0

2

1

2

0

1

1

0

0

1

Are changes needed?

 

Yes

Yes

No

Yes

Yes

Yes

Yes

Yes

No

 

 

How many students or families have expressed an interest in receiving services in a postsecondary setting? _______6___________

Student Services Needs Assessment Form

 

Name of School:                                                                                                                   School Year:                                         __

 

 

Number of students who will receive special education services until they are 21 who are/have:

1

2

3

4

5

6

7

8

9

10

Age

Receive SSI/

SSDI

 

SSI/

SSDI

Eligible

VR

Eligible

DD/MR

Eligible

Included in general education

classes

Not included in general education classes

Received behavior support

Paid work

Unpaid work

training

Extra curricular activities  in school

Extra curricular activities  outside of school

Received travel training

Required 1:1

21=

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

20=

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

19=

 

 

 

 

 

 

 

 

 

 

 

 

 

18=

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

17=

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Are changes needed?

 

 

 

 

 

 

 

 

 

 

 

How many students or families have expressed an interest in receiving services in a postsecondary setting? __________________

Instructions for Use

Student Services Needs Assessment Form

1.      Identify the sending school and school year on the top of the form.

 

2.      In Column 1 write the number of students from the school that that are in each age bracket listed.

 

3.      In Column 2 write the number of students that are currently receiving or are eligible to receive Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI) from the Social Security Administration (SSA). Students' eligibility status may be one of the characteristics used to describe students during the referral process. In addition, school personnel can determine if students who may be eligible have completed the necessary paperwork.

 

4.      In Column 3 write the number of students who may be eligible to receive services from your state vocational rehabilitation office. If students may be eligible, but have yet to apply for services, this is a need that can be addressed by school personnel in an existing program.

 

5.      In Column 4 write the number of students who may be eligible to receive services from your state developmental disabilities case management agency (Office of Mental Retardation or Developmental Disabilities Administration). If students may be eligible, but have yet to apply for services, this is a need that can be addressed by school personnel in an existing program.

 

6.      In Columns 5 write the number of students who have or have not participated in general education classes. This helps elicit the extent to which students in this school have had inclusive experiences and facilitates discussion regarding students' need for expanded opportunities in this area.

 

7.      In Column 6 write the number of students who have a behavior support plan. Students' behaviors may impact their possible referral to a program.

 

8.      In Column 7 write the number of students in each age range that have had paid and unpaid employment experiences. This will provide personnel with a summary of the students' vocational experiences, clarify how these experiences differ by the age of the student, and highlight potential areas in which changes in vocational services need to be made.

 

9.      In Column 8 write the number of students who have participated in extra curricular activities both in and outside of school. The goal of this is twofold. First, this information can be used to identify student activities of interest that may be expanded or enhanced in a new or updated program. Secondly, participation in extracurricular activities is an area of transition that is often overlooked and could be addressed in a program in a postsecondary setting as well as in the existing high school program.

 

10.  In Column 9 write the number of students who have received travel training. Travel training provides students with access not only to employment but also to community resources and recreational facilities. If an emphasis has not been placed on travel training in the high school, it may be possible to make this change in the existing program or to make it a focus in a new program.

 

11.  In Column 10 write the number of students in each age range that require 1:1 assistance. This not only pinpoints the extent of support the student population requires but may also be a future personnel issue.

 

 

12.  At the bottom of the Form, write the number of students or families that have expressed an interest in receiving services outside of the high school. Often this is one of the most critical factors in developing new programs outside of the high school setting.


Review Questions for Student Services

1.      Are changes needed for a particular age group (17-18 year olds) or are changes       needed for all students?

2.      What kinds of changes are needed?

3.      Does the issue of student application for Supplemental Security Income (SSI),       Vocational Rehabilitation (VR), or Developmental Disabilities (DD) services or       supports need to be addressed by current school personnel?

4.      Does the amount of self-contained instruction for students need to be changed?

5.      Does the frequency or variety of inclusive experiences need to be increased?

6.      Should more students have paid jobs?

7.      Do students need increased opportunities to participate in recreational or       extracurricular activities with same age peers?

8.      How could the frequency and level of independence for students be improved by increasing their travel training?

9.      Could the changes identified in Questions 1-8 be addressed in the current high       school setting?

10.  Do the changes identified in Questions 1-8 require the development of new services in a postsecondary setting such as a college campus or business site?

11.  How will services provided in the postsecondary setting be different from what        is currently available?

12.  What setting is best equipped to meet students’ needs?

13. Which of the changes identified should be given the highest priority?

 
 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 



Examples of Changes in Service

(Examples taken from data provided Sample Needs Assessment Form for Wilson High School)

 

Text Box: Employment. Only one of the 17 or 18 year old students with significant disabilities at this school have had paid work experiences and two students have not had any unpaid work experience. Students need to have increased career-training activities at age 17 and 18. These changes could be addressed in the current program by offering students opportunities to receive unpaid experiences in community employment setting that are already used by the school system. Inclusive Experiences. None of the students ages 19-21 are participating in any general education courses. As these students have no opportunity to interact with their same age peers (as most high school students graduate at 18), it would be difficult to address this area of need within the context of the high school. This change could be addressed by accessing educational opportunities for students at a local community college or continuing adult education program in an area of interest. Courses could be audited or taken for credit in such areas as physical fitness, computer literacy, basic math or reading, or any other area of student interest. Developing a program in a college or community setting could also address this need. Extracurricular Activities. Student participation in extracurricular activities has occurred for only 1 of the 12 students assessed on this form. Supporting students in developing recreational and social activities is also an area in which changes are needed. These changes could be addressed within the current program by involving students in during and after school clubs, organizations, or athletics. In addition, student participation in local recreational activities outside of school could be facilitated through a partnership with the local YMCA, Park and Recreation Department, or other youth organizations. Travel Training. The assessment reveals that only 3 of the 12 students have received any form of travel training. As lack of transportation limits many aspects of life (accessing employment, recreation, community resources), this is an area in which changes are needed. These changes could be met within the current program by providing students with access to the county bus system, or by helping students to learn how to call for and pay for a cab ride to their desired destination. These changes could also be addressed by establishing a new program located in a community or college setting that was close to the available transportation options.  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 



Action Plan for High School Services Form

 

Action Plan of                                                               Public School System

(Fill in Name of School System)

Date Created:                                                                                              

Name and Title                                                                                             Agency                                 

                                                                                                                                                                       

                                                                                                                                                                       

                                                                                                                                                                       

                                                                                                                                                                       

                                                                                                                                                                       

                                                                                                                                                                       

                                                       

Actions Needed:

Person  Responsible

Timeline

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

                 

Next meeting date:


Sample Action Plan for High School Services Form

 

Action Plan of              Buckman County                 Public School System

(Fill in Name of School System)

Date Created:                                10/2/02                                  

Name and Title                                                                                             Agency                                 

        Donna Flanagan, Director of Special Education                             BCPS

        Marjorie Mitchell, Special Education Teacher                                BCPS

        Sharon Whitney, Transition Specialist                                            BCPS

        Brian Vandever, Parent

        Katie Johnson, County Transition Supervisor                               BCPS

        Brenda Kelley, Counselor                                                   Vocational Rehabilitation                                                                  

Actions Needed:

Person  Responsible

Timeline

Provide job training experiences to students at age 17-18

-schedule meeting with transition personnel and job coaches

-review current job tryout placements

-conduct interest inventories/situational assessments with all 17 and 18 year olds

Investigate paid positions for students

-Job development at mall

-Meet with current training supervisors to explore possible paid positions

-Contact local workforce investment board

-Contact chamber of commerce, get on committee

Provide travel training on Metro bus 1 x /week to all 17-18 year old students

Improve partnerships with local adult service providers

-Schedule meetings with Supported Employment Enterprises and Cerebral Palsy of B.C.

Facilitate participation in extracurricular activities for students ages 17-18

 

 Katie Johnson

 

 

 

 

 

 

 

 

 

 

Katie Johnson

Sharon Whitney

 

 

 

 

Donna Flannagan

 

Donna Flannagan

 

 

Sharon Whitney

Brenda Kelley

 

 

Marjorie Mitchell

 

 

 

 

 

Katie Johnson

12/1/03

 

 

 

 

 

 

 

 

 

 

 

All year

 

 

11/25/03

 

11/1/03

 

11/1/03

 

 

1/15/04

 

 

 

 

11/15/03

 

 

 

 

10/1/03

                 

Next meeting date: 12/15/03 at Wilson High School Conference Room

 

 

Instructions for Use

Action Plan for High School Services Form

 

1.      Write the name of the school system at the top of the action plan

2.      Indicate the date the action plan was written

3.      Have all members of the committee involved in designing the action plan write their names, positions, and the agency in which the work. Any member who is not present at the meeting should not be deemed responsible for any of the actions on the plan.

4.      Reiterate the list of changes needed in the high school program that was created upon review of the needs assessment data.

5.      List the actions that are needed to meet these needs.

6.      Designate a person who will be responsible for completing these actions.

7.      Create a timeline in which the actions will take place.

8.      Determine a date and place of a follow up meeting for the committee to review progress toward implementing the action plan.