Assistive Technology Self-Care
Assessment Checklist
Name:
Reporter:
Date of Birth:
Current Self-Care Ability: (Check all that apply.)
1.
Organizing and maintaining school supplies and materials:
Puts objects/materials into large containers (desk, shelves, cubbies)
Puts objects/materials into small containers (pencils or scissors into container)
Takes out and puts away book in desk
Gets items from own bag/pocket and gives to another (homework, lunch money)
Removes pull-off lids from containers
Disposes of trash in proper receptacle
Picks up objects from floor
Passes objects/papers along to other students
2.
Independent participation in school lunch:
Selects foods directly or by indicating to helper
Carries tray through line
Eats regular lunchtime/snacktime foods without choking
Drinks from a cup or glass
Pours liquid from carton or pitcher
Eats finger foods
Brings food from plate/container to mouth using fork or spoon
Drinks without spilling from at least one type of container
Opens milk carton
Eats within allotted time
Uses napkin to wipe face/hands
Disposes of leftovers/trash properly
3.
Independent clothing management:
Removes front-opening garment (sweater, coat)
Puts on front-opening garment (sweater, coat)
Zips and unzips (not including separating zipper)
Hangs clothing on hook or hanger
Secures shoes by tying or Velcro
Separates and hooks zippers
Form 2.1
Self-Care
Page 1
Assistive Technology Assessment Checklist
Self-Care (continued)
4.
Maintaining personal hygiene:
Wipes nose
Covers mouth/nose with hand or tissue when coughing or sneezing
Brushes teeth
Washes face
5.
Using restrooms independently:
Indicates need to be changed/toileted
Closes and secures bathroom stall or door
Zips and unzips pants
Lowers garment bottoms from waist to knees
Transfers to toilet from standing or wheelchair
Voids within a reasonable amount of time
Obtains toilet paper from roll or dispenser
Wipes or cleans self after toileting
Transfers from toilet to standing or wheelchair
Pulls up garment bottoms from knees to waist
Buttons pants
Fastens belt buckle
Obtains soap from any type of dispenser, or holds and applies bar soap
Washes hands
Obtains towel from dispenser, dries hands
Turns water faucet on/off
Pushes handle to flush toilet
Cares for toileting needs in timely fashion to avoid soiling
6.
Current assistive technology being used by student:
Adaptive eating/drinking utensils (foam handle on utensil, bent spoon, cup with cut-away rim)
Adaptive dressing equipment (button hook, reacher)
Adaptive toileting equipment (grab bars in bathroom, special seat)
Organizational materials (desk organizers, schedule books, picture cues)
Form 2.1
Self-Care
Page 2
Assistive Technology Assessment Checklist
Self-Care (continued)
7.
Current assistance available:
Adult assistance available in classroom as needed
Adult assistance available on call
Peer helpers for
Summary of self-care abilities and concerns:
Form 2.1
Self-Care
Page 3