BELTON HIGH SCHOOL TRANSITION SURVEY

TRANSITION ASSESSMENT/INTERESTS, PREFERENCES, STRENGTHS & NEEDS

Full Name: Birthdate: / / Age:

Address:
Phone #: Cell #: Goal Area(s):
Parent/Guardian Name: Work #:

JOBS & JOB TRAINING

FUTURE ADULT GOAL: After high school, the kind of job I would like to have is:
(List some careers that you are interested in)

Circle the paid or unpaid jobs that you have had:

Farm work Babysitting Housecleaning Lawn Mowing
Odd Jobs Other (List):
Which was your favorite?
Why?
Which was your least favorite?
Why?
Do you currently have a job? YES / NO
Where do you work?
What are your responsibilities?

Circle the items that best describe what you like in a workplace:
Part-time Full Time Indoor Outdoor
Active & Physical Sit down Near Home Big city
Large business Small business Being with people Working Alone
Work for someone Own your own business Enjoy my work Money is most important
Working with hands Working with pen & paper Use Technology Not using technology

After you graduate from high school, will you get a job and work right away? YES / NO
Would your disability affect your job? YES / NO
If yes, how?
Do you have an up-to-date resume? YES / NO
Have you participated in an interview? YES / NO
Where?
Have you filled out a job application? YES / NO
For what company?
Do you willingly follow directions? YES / NO
Do you follow through on directions given at home? YES / NO
Circle your job-related strengths (things you are good at) and put an “X” on
your job-related weaknesses (areas you need to improve):
Getting along with peers your own age Getting to work/school on time
Getting along with older people/adults Keeping focused on assignments
Making eye contact Willing to ask questions
Listening carefully when others speak Treating others with respect
Completing your basic education Accepting help from others
Standing up for your rights Keeping your cool when frustrated
Dealing with personal or family problems Feeling confident
Finishing your work with reminders Using time wisely
Figuring out the next thing to do Grooming /Hygiene
Changing from one job/task to the next Keeping a positive attitude

Circle the volunteer work you have done in your community:

Clean ditches Work at church Teach Sunday school
Child care Girl Scouts Boy Scouts Other:
Do you independently get ready for school? YES / NO
Do you get to school on time? YES / NO
Do you start tasks on your own without being told? YES / NO
Do you have good school attendance? YES / NO
Do you usually make an effort to do your best? YES / NO
Do you use a calendar or planner to organize yourself? YES / NO
Do you shove or push in the hallway? YES / NO
Do you give your friends “put downs”? YES / NO
Do you use your time in class to work on assignments? YES / NO
Do you cooperate with others when working on projects? YES / NO
Are you organized at school? YES / NO
 POST SECONDARY EDUCATION & TRAINING
FUTURE ADULT GOAL: After high school, I would like to:
Do nothing Join the military Unsure Get a full-time job
2 year technical college: where? 4 year college: where?

Circle the things in school that are difficult for you:

Students Teachers Lunch time Attendance Focusing

Bus Rides Activities Tardiness Homework

Which classes are the most difficult for you?

Why are they hard for you?

Which classes are the easiest for you?

Why are they easy for you?

Do you cooperate with others when working on projects? YES / NO

Circle the accommodations (help) that you ask your teachers for:
More time to complete tasks Help with reading Use of a calculator Modified tests
Different seat arrangement Help with spelling Help taking notes Shortened tests
Shortened assignments Other:

Circle what could help you to be more successful in school:

Do homework at home Learn how to study Read for fun
Quiet/special place to study at home Review information on my own
Are you currently working to the best of your ability in school? YES / NO
How much time do you spend completing homework each night?
Do you have good study skills? YES / NO
How do you learn the best? Lecture (hear it) Visual (see it) Doing things w/your hands
What are your responsibilities?

How do you plan to pay for college or training after high school?
Parents Yourself Loans Scholarships
What does IEP stand for?
Who can you get a copy of your IEP from?

Circle the following things that you need help with:

Reading: Fill in the blank questions Essay questions Short books

Homework instructions Restaurant menus Novels

Newspaper headlines Cooking directions Textbooks
True/False questions Magazine or newspaper articles
Recognizing words Understanding what you have read

Writing: Short answers on tests Essay answers on tests Spelling

Punctuation Letter to a friend Directions to someplace
Phone message Paper for a class
Job application Grocery list

Math: Adding Subtracting Multiplying

Dividing Exact measurement Fractions
Using a calculator Figuring length of trips Decimals
Making change Developing a budget

My level of motivation to succeed in school is: High Medium Low

COMMUNITY PARTICIPATION
FUTURE ADULT GOAL: After high school, I would like to participate in the following:
(Circle all that you might do)
Church Group Volunteer Fire Department Rescue Squad
Club Plays Concerts
Sports: Bowling Volleyball Softball Basketball Swimming

Others:
Have you taken your Permit test?
YES / NO Did you pass? YES / NO

Have you taken Driver's Education? YES / NO

Do you have a Driver’s License or an ID Card? YES / NO

Do you have a savings account? YES / NO A checking account? YES / NO

Do you have a debit or credit card? YES / NO

 Circle the places you go regularly in your community:
Work Bowling Library Movie
Grocery shopping Pool Health club Post Office
Laundromat Parks Mall Plays
Museums Concerts Church Sporting events
Court house Job service Dentist Doctor
Community Ed. & Rec. Boy Scouts Girl Scouts FFA
4-H Other:

Circle all the modes of transportation you use to get around in the community:
Parents/relatives car Drive self Walk Bike
Car-pooling with friends Friends car Taxi Bus

Circle the appointments that you make yourself:

Hair Doctor Dentist Other: None
Do you keep appointments that you or someone makes for you? YES / NO
If you can’t make it to an appointment, do you call and let them know? YES / NO
Do you know the names/phone numbers for all your appointments? YES / NO

RECREATION & LEISURE

FUTURE ADULT GOAL: After high school, in my free time, I would like to:

List your hobbies?

Do you enjoy reading for fun? YES / NO Circle the things you enjoy reading:
Newspaper Magazine Novel Books
o Where did you go and what did you do on y ur last vacation?
Have you helped plan a vacation? YES / NO If yes, where?

What do you like to do when you have free time alone?

What do you like to do when you have free time with friends?
What do you like to do when you have free time with family?

Circle the places you go for fun:

Mall Out to eat (restaurants) Movies Gym

Sporting events Other:

List the sports you enjoy watching:
 Do you exercise regularly? YES / NO What do you do?

Circle the activities that you enjoy participating in:

Walking Rollerblading Volleyball Gardening Playing an instrument
Construction Hunting Fishing Swimming Being with animals
Biking Hiking 4-Wheeling Bowling Listening to music
Boating Baseball Concerts Playing cards Writing letters
Sewing Shopping Crafts Camping Canoeing
Riding a horse Lifting weights Skiing Movies Watching videos

Car racing Fixing cars Reading Running

INDEPENDENT LIVING SKILLS

FUTURE ADULT GOAL: After high school, I would like to live:

At home In a house Apartment College dormitory

In a big city In the country In a town With relatives
With friends Alone Group home

Underline the chores you know how to do andcircle the ones you do regularly:
Cook Dust Dishes (by hand or dishwasher) Vacuum Take out garbage
Garden Sweep Wash, fold or put away clothes Shovel snow Mow the lawn
Grocery shop Make your bed Clean bedroom Clean bathroom
Shovel Wash
snow windows Rake leaves
If you had to make breakfast for your family, what would it be?

If you had to make lunch for your family, what would it be?

If you had to make supper for your family, what would it be?

Do you eat well balanced, healthy meals each day? YES / NO

Do you limit the amount of junk food you eat? YES / NO

Do you maintain your weight at a good level? YES / NO
Can you use basic tools to fix things around the house? YES / NO
Can you independently take medication according to the label? YES / NO
List any major medical problems that you have:

What time do you usually go to bed?

Get up? Are you tired in school? YES /
NO
Do you get yourself up in the morning? YES / NO
Do you have good personal grooming and hygiene habits? YES / NO
Do you have good health habits (avoid tobacco, alcohol, drugs, etc.)? YES / NO
Have you ever stayed at home alone? YES / NO
Have you ever spent the night away from home? YES / NO