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Fayette-Greene-Washington
INTERMEDIATE UNIT 1
Mr. Charles F. Mahoney
Executive Director
One Intermediate Unit Drive
Coal Center, PA 15423-9642
Telephone 724-938-3241 Fax 724-938-8722
www.iu1.org
Date Completed
Date Updated:
Student Academic Transition Survey
Student’s Name:
Date of Birth: ________________
Expected Year of Graduation: ________________
Date of Original Survey:
School District:
Grade:
Date Updated:
School District:
Grade:
Date Updated:
School District:
Grade:
Intermediate Unit 1 does not discriminate on the basis of race, color, national origin, sex, disability, age, religion,
ancestry or any other legally protected classification in its educational programs, activities or employment practices
1/11/10
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Secondary Academic Transition Survey
Student Form
Please complete this future-planning document for your upcoming IEP conference.
General Student Information
Your Name:
First
Person Living With:
Anticipated Graduation Date:
Current Address:
Middle
Birth Date:
Grade:
Phone Number:
Parent’s Name:
Cell Phone:
Last
I. Vocational/Post-Secondary Education Options
A. Upon graduation, what do you see yourself doing for future education or training? (Check all
that apply)
Four-Year College/University
Community College
Technical College
Occupational Training Program (Eligibility Requirements)
Military Service
Community Education Program
What will you be studying or training to be?
What is your level of motivation to succeed in the academic setting?
High
Medium
Low
What is your level of control over decision-making and your individual success?
High
Medium
Low
What is your ability to identify what you needs and how to get it?
High
Medium
Low
B. Upon graduation, in what kind of employment setting do you see yourself?
Competitive Employment:
Self-Employed:
Supported Employment:
Full-Time
Full-Time
Full-Time
Part-Time
Part-Time
Part-Time
Intermediate Unit 1 does not discriminate on the basis of race, color, national origin, sex, disability, age, religion,
ancestry or any other legally protected classification in its educational programs, activities or employment practices
1/11/10
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C. What type of job/occupation do you see yourself working in one year after graduation?
D. What work-related demands are being placed on you at home, and what is your reaction to
them?
Activity
For example, makes beds, carries
out trash mows lawn.
1)
2)
3)
4)
5)
Degree of Independence
Does Independently
Needs Guidance
Unwilling to
Perform Task
E. List any jobs or chores you do now and enjoy.
F. What jobs or work experience have you had?
G. List any jobs you really dislike.
II. Home Living Options
A. Where do you think you will most likely live after graduation?
What City or Town?
B. (Please check one from this list.)
Live independently in apartment or home.
With family member (who?)
College dormitory (where?)
Other, please describe.
Intermediate Unit 1 does not discriminate on the basis of race, color, national origin, sex, disability, age, religion,
ancestry or any other legally protected classification in its educational programs, activities or employment practices
1/11/10
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III. Recreational and Leisure Options
A. Leisure Interest Inventory
Check all of the following leisure activities you do during your free time:
Participate in Athletic/Sports Activities:
Swimming
Running
Softball
Walking
Riding Bike
Other:
Lifting Weights
Aerobics
Basketball
Fishing
Bowling
Skiing
Riding Motorcycle
Canoeing
Camping
Riding Horses
Attend Large Group Events:
Movies
Ball Games
Music Events
Other:
Car Races
Horse, Dog, Car Shows
Community Education Classes
Participate in Individual Activities:
Sewing
Handcrafts
Reading
Caring for Pets
Talking on Phone
Clean/Repair Car
Listen to Music
Cooking
Playing Instrument
Writing Letters
Watching TV
Other:
Shopping
Playing Pool/Billiards
Caring for Lawn
Playing Video/Arcade Games
Playing Cards or Board Games
Participate in Social Activities:
Dating
Entertaining at Home
Attending Church
Picnicking
Volunteering
Belonging to a Social Club
Eating Out
Dancing
Driving Around
Other:
Spending Time with Family or Friends
Intermediate Unit 1 does not discriminate on the basis of race, color, national origin, sex, disability, age, religion,
ancestry or any other legally protected classification in its educational programs, activities or employment practices
1/11/10
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IV. Transportation Options:
A. How will you get around the community and to work?
Do Now
Need to Learn
Drive Own Vehicle
Drive Family Vehicle
Use Public Transportation
Take Taxi
Ride Bicycle
Walk
Depend on Others
Other:
V. Financial Support:
A. Do you need financial assistance in any of the following areas to reach your long-range goals?
1. Post-Secondary Education
Yes
No
If yes, check all of the following for which you would like information.
Office of Vocational Rehabilitation (OVR)
Pell Grants
Scholarships
Work Study
Student Loans
Supplemental Security Income (SSI)
Social Security Disability Insurance (SSDI) (i.e., PASS)
Pennsylvania Higher Education Assistance Agency (PHEAA)
2. Employment Assistance
Yes
No
If yes, check all of the following for which you would like information.
Office of Vocational Rehabilitation (OVR)
Supplemental Security Income (SSI)
County Social Services (MH)
Office of Developmental Programs (MR)
Intermediate Unit 1 does not discriminate on the basis of race, color, national origin, sex, disability, age, religion,
ancestry or any other legally protected classification in its educational programs, activities or employment practices
1/11/10
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3. Home Living Assistance
Yes
No
If yes, check all of the following for which you would like information.
County Social Services
Supplemental Security Income (SSI)/Medical Assistance
Housing Assistance
B. Which of the following agencies have you contacted with regard to financial support?
Not Applicable
Office of Vocational Rehabilitation (OVR)
Social Security Office
County Social Services (MH/MR)
Other, please describe
VI. Health-Related Needs:
A. Do you currently have any of the following needs?
Medical (i.e., medications)
Counseling
Other
Yes*
Yes*
No
No
*Please Explain:
B. What are some possible supports you may require in the future?
VII. Currently, what is your greatest concern about the future?
Intermediate Unit 1 does not discriminate on the basis of race, color, national origin, sex, disability, age, religion,
ancestry or any other legally protected classification in its educational programs, activities or employment practices
1/11/10