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Community-based Instruction
Anderson School District Five
Community Based Instruction (CBI) is a program designed for students that need instruction in
functional and daily living skills. The goal of the program is to provide hands on learning activities at
all age levels to help students acquire the skills to live in the world today. Domains to be covered
include the following:
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Domestic – includes the area of personal health care, home health care, and interpersonal
relationships. This area also includes emergency safety skills, nutrition, hygiene, dressing and
eating. Home health care could be the payment of bills, insurance, cleaning, general house
keeping.
Recreation/Leisure – These should reflect the student’s age, interests, as well as family
activities, culture and involvement with community facilities. Should span a wide range of
activities to include the involvement of other people or individual activities. Examples could be
bowling, putt-putt, visiting the local YMCA, going to the library, drawing class (arts/crafts)
Community/Mobility – this domain should examine all possible means of community access.
City buses, taxi service, planning activities that are in student’s area.
Community/Consumer – purchasing or service related activities in the student’s immediate
area. Examples include grocery shopping, clothes or gift shopping, miscellaneous shopping (e.g.
browsing, buying records, plants), banking skills, using the post office, or visiting the social
security office.
Vocational – should consist of real work experience in real work settings. This would involve
visiting work sites to observe people at work. Observing various jobs at your school could be
one area to investigate.
Guidelines:
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Permission forms must be obtained prior to participating in any activity.
Permission forms must be taken on all CBI trips.
Community-based instruction must be tied to IEP goals.
Students must have some form of identification with them.
Student Locator form submitted to school office prior to leaving grounds.
Submit reimbursement form as soon as possible.
CBI trips are NOT field trips. CBI is a way to reinforce what is being taught in the classroom.
Each domain should be addressed at least once per school year.
CBI trips should be individualized. It may not be appropriate for all students to participate in
all activities.
10. All students must have appropriate supervision whether they’re staying at school or
participating in CBI trip.
11. CBI may only take place within Anderson School District 5.
12. Trip is cancelled if having inclement weather.
13. Trip is cancelled if teacher cannot participate.
14. Contact coordinator IMMEDIATELY if CBI trip is to be cancelled.
15. May attend only one location during trip.
16. ALL transportation issues must go through coordinator such as scheduling, canceling,
questions...) teachers/parapros should not contact transportation.
17. CBI times 10:30-12:30. Any request for variation on time(s) should be submitted with initial
schedule submission.
18. Adhere strictly to times – just because you leave late does not mean you can stay late!
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Community-based Instruction Checklist
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Appropriate IEP goals are on IEP
Permission forms obtained
Locations contacted to arrange CBI visit
Schedule/Plan submitted to coordinator
Reimbursement form submitted to coordinator
Appropriate supervision planned for all students
Student locator completed and submitted to front office at school prior to leaving school
Copies of permission/medical emergency/photography prepared to take
Emergency Procedures
Lost student:
 Contact school principal immediately
 Two adults present: one searches for student, other stays with remaining students
 One adult present: entire group searches
 Contact security
 10 minutes – student not found – contact school principal for further instructions
 Notify all appropriate persons when student is located
 Write a summary of the incident to submit to principal and coordinator
Medical Emergency:
Minor
 Assess the situation
 Use the first-aid supplies
 Call school site, if necessary
 Complete accident/incident report upon returning to school
Major
 Assess the situation and if life threatening:
Supervising adult should:
1. Request responsible person to call 911
2. Notify school principal ASAP
3. Remain with the student to administer first aid
4. Accompany the victim to the emergency facility with emergency info
5. Complete incident report
Designated staff member or other responsible person should:
1. Call 911 as directed
2. Be prepared to give the following information:
 victim’s condition
 location of the emergency
3. Arrange to have the students supervised in a different location
4. Meet the Emergency Medical Services (EMS) personnel and direct them to the specific
location of the emergency
5. Write summary of incident
(July, 2015)
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Community-based Instruction
Parental Permission
_______________________________________ _____________ ______________
Student
Date of birth
School
___________________________________________________________________
Address
Dear Parent/Guardian/Student of Majority Age:
Community-based Instruction (CBI) is a program designed for students that need instruction in
functional and daily living skills. The goal of the program is to provide hands on learning activities
within the community to help students acquire the skills to live and function with their community.
Students participating in CBI will have the opportunity to travel to sites within the community during
school hours to practice and acquire skills. Their teacher and other school personnel will accompany
the students on these off-campus trips.
CBI provides instruction in basic life skills through four domains:
o Domestic (Examples: personal grooming, nutrition, laundry, cooking)
o Vocational: (Examples: job readiness such as being on time, following rules)
o Community: (Examples: transportation, library, shopping centers, post office)
o Recreation and Leisure: Examples: crafts, parks, bowling, movie theaters)
I give permission for my child to participate in Community-based Instruction and to visit places
within the community during school hours.
AND
Permission is also granted for the provision of medical care in case of injury or accident involving my
child. In case of emergency involving the above-student, the teacher should contact one of the
persons listed below at the phone number(s) as indicated if unable to contact parent/guardian.
I appoint or designate a physician and/or medical center/hospital to carry out the necessary
treatment in the event my child should, for any reason, require minor or major medical treatment. I
understand that I will be contacted immediately in case of an emergency.
________________________________________________________
Parent/Guardian/Student of Majority Age
Relationship to Student
Phone
Date
____________________________________________________________________________________
Medical conditions/Allergies
____________________________________________________________________________________
Doctor’s name
Phone number
Medicaid number
PHOTOGRAPHY/VIDEOTAPE
□
□
My child
does
does not have permission to be identified, interviewed, and/or photographed or
videotaped for use by the media and/or school district regarding:
o Community-based Instructional activities and/or Supported Employment and Exploration
activities (Work crew, Cooperative Placements, Job Shadowing, Internships)
________________________________________________________
Parent/Guardian/Student of Majority Age
(July, 2015)
Relationship to Student
Phone
Date
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Community-based Instruction
Student Locator Record
____________________________________________________________
Teacher
Class
Date
Person responsible for students remaining: _________________________
SpEd Assistant(s) out of building: _________________________________
Students on CBI trip:
1. __________________________
7. __________________________
2. __________________________
8. __________________________
3. __________________________
9. __________________________
4. __________________________
10. _________________________
5. __________________________
11. _________________________
6. __________________________
12. _________________________
Location of CBI trip:
_____________________________________________________________
Transportation by (circle one):
School bus
Walking
Time Out: _______________ Estimated time of return: ________________
Form is to be completed and given to the school secretary
before leaving the campus.
Community Based Instruction
Schedule/Plan
__________________________________________________________________________
Teacher
School
Class
Date Submitted
Nine week period: ___ 1st
___ 2nd
___ 3rd
___ 4th
(This may be submitted every nine weeks or semester)
Date: ______________________ Training Site: ________________________________ __________________
Domain: ____________________Activity: _______________________________________________________
Date: ______________________ Training Site: _______________________________________ ____________
Domain: ____________________ Activity: _______________________________________________________
Date: ______________________ Training Site: ___________________________________________________
Domain: ____________________ Activity: _______________________________________________________
Date: ______________________ Training Site: ____________________________________________________
Domain: ____________________ Activity: ________________________________________________________
Date: ______________________ Training Site:____________________________________________________
Domain: ____________________ Activity: _______________________________________________________
Must be approved by the school principal before transportation arrangements will be made.
_________________________________________________
Principal’s Signature
Date
_________________________________________________
Coordinator’s Signature
Date
Participants: Adults ______
Students/wheelchairs ______
(July, 2015)
Students ______
Total _______
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FUNDS REQUEST FOR COMMUNITY-BASED INSTRUCTION
TEACHER:____________________________ SCHOOL: _______________________
PURPOSE
Community-based Instruction 15/16 school year
Students based on October 1 caseload = ____
_______ X 10.00
Total to be disbursed to teacher:
AMOUNT
$100.00
+
$_______
Account:
Self-contained/Life Skills classes
(SpEd will insert upon receipt)
I understand these funds are to be used
For community-based activities and/or
Supplies to enhance the CBI experience.
Approved by:
______________________________
Signature of Claimant
____________________________
Coordinator
______________________________
Date
____________________________
Director
____________________________
Date
(July, 2015)