ࡱ> ;=89:5@ ^ bjbj22 "XXV0000000D````aDbXrXrXrXr~L H $<R3 0М{.~ММ300XrXrK @<<<М.0Xr0Xr <М <<R 00Xrb `5f,7`> V0*<*<DD0000*0$(<<ߙ33DDd^`2 DD`CLIENT PERSONAL DATA SHEET {PICTURE HERE}  FORMTEXT  Client's Name      FORMTEXT  Address      FORMTEXT  City, State, Zip      FORMTEXT  Area Code, Phone #      FORMTEXT  Alternate Phone #      FORMTEXT  Social Security #      FORMTEXT  CONTACT PERSON   FORMTEXT  CONTACT'S PHONE   FORMTEXT  HEIGHT   FORMTEXT  WEIGHT  UNIVERSAL WORKSHOP EMPLOYEE TRAINING AND DEVELOPMENT Case Record Review Name:  FORMTEXT       Completed by:  FORMTEXT       Date:  FORMTEXT       Photo & & & & & & & & & & & & & .& & & & & & & & & & & & & & & & & &  FORMCHECKBOX  Filing Guide & & & & & & & & & & & & & & & & & & & & & & & & & & & & &  FORMCHECKBOX  Identifying Information Face Sheet & & & & & & & & & & & & & .& & & & & &  FORMCHECKBOX  Interview Form  FORMCHECKBOX  Referral Form  FORMCHECKBOX  PLB Consumer Eligibility Form . FORMCHECKBOX  Sheltered Workshop Application (DESE)  FORMCHECKBOX  Signed Releases Exchange of Information to PLB .. FORMCHECKBOX  Exchange of Information to Workshop.. FORMCHECKBOX  30-Day Meeting Summary .. FORMCHECKBOX  Statement of Objectives  FORMCHECKBOX  Individual Objectives  FORMCHECKBOX  Monthly Graphs & Narrative  FORMCHECKBOX  Vocational Assessments .. FORMCHECKBOX  Psychological Report  FORMCHECKBOX  Baseline  FORMCHECKBOX  Communication Log  FORMCHECKBOX  Notification of Rights  FORMCHECKBOX  Client Input .. FORMCHECKBOX  Daily Data . FORMCHECKBOX  UNIVERSAL SHELTERD WORKSHOP Trainee Record Filing Guide --Client Personal Data Sheet (photo) --Case Record Review (filing guide) --Trainee Record Filing Guide (abbreviation guide & acronym list) --Entrance Discharge Criteria --Discharge Summary (optional-if one is needed) --New Trainee Procedures Profile Referral/Identifying Information Form (face sheet) Interview (2 pages) Consumer Eligibility Form (PLB form) Sheltered Workshop Application (DESE) Authorization For Exchange of Findings (signed releases-3 pages) Training Plan Training Plan Summary 30-Day Summary Statement of Goals and Objectives (strength & needs) Training Plan Objectives (individual objective & monthly graph-2 pages) Assessment & Evaluations Summary of Assessments (vocational assessments-signed & dated & baseline-4pages) Productivity, Time on Task, Accuracy Graphs Trainee Follow-up Form Psychological Report Communication Communication Log (telephone calls, conferences) Universal Workshops Individual Rights (notification of rights-2 pages) Trainee Input (client input) Incident/Injury Report (if one is needed-2 pages) Data Behavioral Data Sheet Behavioral Log UNIVERSAL SHELTERED WORKSHOP EMPLOYEE TRAINING AND DEVELOPMENT Entrance/Discharge Criteria ENTRANCE CRITERIA: Classified as mentally retarded or developmentally disabled by the St. Louis Regional Center. Twenty-one years of age or older. Qualified for eligibility criteria of funding source, specifically (1) and (2) above and residency criterion (St. Louis County resident for the PLB) Employed and meets entrance criteria of host workshop. Access to sufficient information to initially document all of the above. DISCHARGE CRITERIA: Successful movement through the training program resulting in unassisted full-time placement in the regular workshop. Referral to a more appropriate vocational program which better meets the needs of the trainee, i.e. supported or competitive placement. Sufficient factual data to indicate one of the entrance criteria were incorrect or false, i.e. disability incorrectly classified, residency incorrectly documented, or true age is under twenty-one. Employee moves or changes permanent residence to a location not funded by grant. Termination of employment by the workshop. Training programs staff are unable to serve the workshop employee. This includes inability to help the individual engage in appropriate work behavior, when their inappropriate behavior is a danger to themselves or others, and the inability of staff to meet the employees ongoing medical needs. In all cases, full documentation of Universals staffs attempts to best serve the employee of the workshop is to be identified in the discharge summary. Universal Commitment: The staff of Universal Workshop are committed to the people they serve to continually reduce the level of restriction in a persons program, offering as much independence and as many choices as the person is capable of. Also, we continually work towards community integration opportunities when possible. UNIVERSAL SHELTERED WORKSHOP EMPLOYEE TRAINING AND DEVELOPMENT Discharge Summary Client:  FORMTEXT       DOB:  FORMTEXT       Address:  FORMTEXT       Dates Enrolled:  FORMTEXT       to  FORMTEXT       Parent/Guardian:  FORMTEXT       Address:  FORMTEXT        Reason For Discharge:  FORMTEXT       Findings And Progress During Enrollment in Program:  FORMTEXT       Recommendations And/Or Arrangements For Future Program(s):  FORMTEXT       Follow Along Services:  FORMTEXT       ____________________________ ____________________ ______________  FORMTEXT  Typed Name      FORMTEXT  Title      FORMTEXT  Date   UNIVERSAL SHELTERED WORKSHOP New Trainee Procedures Prior to week one Obtain referral form; verify that all line are complete. Coordinator sends letter to parent/guardian with releases. Trainer call Regional Center case manager to inform him/her about referral; obtain information to complete all preliminary forms (Referral form, Identifying Information Face Sheet, Interview form, and demographics.) Week one Fill out PLB Client Information Sheet; original goes to coordinator, keep copy in trainee file. Organize trainee case record, following sample file. Begin baseline on work rate, TOT, accuracy, and behavioral assessments. Week two Continue gathering baseline. Begin vocational assessments. Week three Schedule 30-Day Meeting with trainees interdisciplinary team. Continue baseline and assessments. Obtain copies of DESE application, psychological evaluation, and other applicable information from workshop files. Week four Continue baseline. Complete assessments. Complete Goals and Objectives sheet. Conduct 30-Day Meeting (obtain any additional information needed to complete forms mentioned above, obtain signatures on Meeting Summary Form. Week five Complete Individual Objective Sheet (3 per trainee) and set-up monthly graphs behind each objective. Write Meeting Summary from 30-Day Meeting. Check to be sure that the training plan is complete. Individuals rights. UNIVERSAL SHELTERED WORKSHOP Referral/Identifying Information Form Personal Information Name:  FORMTEXT       Address/Zip:  FORMTEXT       Phone: FORMTEXT       DOB: FORMTEXT       Sex: FORMTEXT       Race: FORMTEXT       SS#: FORMTEXT       Residence Type: FORMTEXT       Transportation: FORMTEXT       Funded by: FORMTEXT       Contact Information Guardian: ( FORMCHECKBOX Self) ( FORMCHECKBOX Other) Name: FORMTEXT       Phone: FORMTEXT       Address: FORMTEXT       Relationship: FORMTEXT       Other Contact: FORMTEXT       Address: FORMTEXT       Phone: FORMTEXT       Case Manager: FORMTEXT       Phone: FORMTEXT       RC ID#: FORMTEXT       VR Counselor: FORMTEXT       Phone: FORMTEXT       Medical Information Primary Disability: FORMTEXT       Level: FORMTEXT       Secondary Disability: FORMTEXT       Medication(s): FORMTEXT       Medicaid#: FORMTEXT       Medicare#: FORMTEXT       Purpose of Medication(s): FORMTEXT       Doctor: FORMTEXT       Address: FORMTEXT       Phone: FORMTEXT       Psychological Information on file at Workshop? ( FORMCHECKBOX Yes)( FORMCHECKBOX No) Medical Information on file at Workshop? ( FORMCHECKBOX Yes)( FORMCHECKBOX No) Referral Information Workshop:  FORMCHECKBOX Valley Ind.  FORMCHECKBOX Universal  FORMCHECKBOX WAC Ind. Referred by: FORMTEXT       Date: FORMTEXT       Phone: FORMTEXT       Reason Referred: FORMTEXT       Date Hired: FORMTEXT       Dates Enrolled: FORMTEXT       to  FORMTEXT       Work History Previous Jobs: FORMTEXT       Dates: FORMTEXT       Previous Programs: FORMTEXT       Dates: FORMTEXT       Work Preferred/Special Skills: FORMTEXT       INTERVIEW Name: FORMTEXT       Date: FORMTEXT       Employment History Previous Jobs:  FORMTEXT       Dates: FORMTEXT        FORMTEXT       Dates: FORMTEXT        FORMTEXT       Dates: FORMTEXT       Previous Programs:  FORMTEXT       Dates: FORMTEXT        FORMTEXT       Dates: FORMTEXT        FORMTEXT       Dates: FORMTEXT       Education Schools Attended:  FORMTEXT       Dates: FORMTEXT        FORMTEXT       Dates: FORMTEXT        FORMTEXT       Dates: FORMTEXT       Grade Level Achieved: FORMTEXT       Did you like school? ( FORMCHECKBOX Yes)( FORMCHECKBOX No) Best Subject: FORMTEXT       Worst Subject: FORMTEXT       Doctor Name: FORMTEXT       Phone: FORMTEXT       Address: FORMTEXT       State: FORMTEXT       Zip: FORMTEXT       Interdisciplinary Team Trainee:  FORMTEXT       Trainer:  FORMTEXT       Parent/Guardian:  FORMTEXT       Residential Staff:  FORMTEXT       Regional Center Case Manager:  FORMTEXT       Voc. Rehab. Counselor:  FORMTEXT       Training Coordinator:  FORMTEXT       Workshop Rep:  FORMTEXT       INTERVIEW Self Assessment What jobs do you prefer?  FORMTEXT       Can you think of anything in the following areas that you would like help learning? Work skills  FORMTEXT       Social skills  FORMTEXT       Daily living skills  FORMTEXT       Other  FORMTEXT       Do you have any goals?  FORMTEXT       If yes, what?  FORMTEXT       General  FORMCHECKBOX  Does individual want to participate in the employee training and development program?  FORMCHECKBOX  Discuss employment options (competitive, supported, enclave, workshop).  FORMCHECKBOX  What is this person s employment preference?  FORMTEXT       Individual is being placed in current program because (check one): an integrated setting cannot be adapted to individual s needs, as evidenced by trial placement in supported employment; or individuals interdisciplinary team has determined that health, skill, or behavioral deficits preclude placement in available positions; or the experience resulting from the current placement is required for, and directly relates to, a normal work situation for which the individual is being prepared.  FORMCHECKBOX  Review entrance and discharge criteria for program. (see attached)  FORMCHECKBOX  Review advantages and limitations of program. (see attached)  FORMCHECKBOX  Review Universal s commitment (see attached)  FORMCHECKBOX  Presenting problem (reason referred FORMTEXT       _______________________  FORMTEXT  Trainee Name  UNIVERSAL SHELTERED WORKSHOP Authorization for Exchange of Findings I hereby authorize Universal Sheltered Workshop Inc. to release to (check one only)  FORMCHECKBOX  St. Louis Office for MR/DD Resources 3663 Lindell, Suite 300 St. Louis, MO 63108  FORMCHECKBOX  Productive Living Board of St. Louis County 121 Hunter Avenue, Suite 200 St. Louis, MO 63124 Information concerning: (first) (middle) (last) (D.O.B.) information about: (subject) This authorization for Exchange of Findings is in effect until _______________ (not to exceed one year) (date) _______________ Signature _________________________ (date) (trainee) _______________ Signature _________________________ (date) (parent or legal guardian, as applicable) _______________ Signature _________________________ (date) (witness/relationship to client) UNIVERSAL SHELTERED WORKSHOP Exchange of Findings Universal Workshop seeks access to information on  FORMTEXT  Employee's Name . This information will be used to supplement the employee application, referral form, and consumer information form. By signing this form the employee (guardian) gives Universal Staff permission to obtain information from the Department of Mental Health: The St. Louis Regional Center. _______________ Signature _________________________ (date) (trainee) _______________ Signature _________________________ (date) (parent/guardian) _______________ Signature _________________________ (date) (trainer) UNIVERSAL SHELTERED WORKSHOP Training Plan Summary Name ____________________________________________________ Date _________ Meeting Summary ________________________________________________________ General Comments________________________________________________________ Team Members: ____________________________________________ ________________________ Employee Date ____________________________________________ ________________________ Parent/Guardian Date ____________________________________________ ________________________ Trainer Date ____________________________________________ ________________________ Workshop Representative Date ____________________________________________ ________________________ Coordinator Date ____________________________________________ ________________________ Regional Center Case Manager Date ____________________________________________ ________________________ Vocational Rehabilitation Counselor Date UNIVERSAL SHELTERED WORKSHOP Statement of Goals and Objectives Name FORMTEXT       Date FORMTEXT       Long Range Goals #1  FORMTEXT  To become an Independent Employee of the Workshop.  Obj#1  FORMTEXT       Obj#2  FORMTEXT        Strengths Needs   FORMTEXT  1      FORMTEXT  1      FORMTEXT  2      FORMTEXT  2      FORMTEXT  3      FORMTEXT  3      Objectives Priority Date Date  (numbered) Yes No Implemented Completed  FORMTEXT  1      FORMCHECKBOX   FORMCHECKBOX   FORMTEXT        FORMTEXT        FORMTEXT  2      FORMCHECKBOX   FORMCHECKBOX   FORM   & ( * , L T V X Z n p r t  {jh";h";5Ujhh";h";5Ujh";h";5Ujxh";h";5Uh`Sh'5h";5mHnHujh";5UmHnHujh";h";5U h";5jh";5Uh'068:<>@BDFHJLNPRTrtvxz|~$a$^  X 8 v    > , d f R  !$a$   , 4 6 8 : N P R T p r t v x Ǻrb^h'jh";h'5UjDh";h'5Uh";h'5mHnHu#jh";h'5UmHnHujh";h'5Uh";h'5jh";h'5U h";5h";5mHnHujh";5UmHnHujh";5UjXh";h";5U$   >      ( * < > R T V ` b . 0 L N P 㿸vkjxh'Ujh'Ujh'Ujh'Ujh'UmHnHujh'Ujh'U h'5\h'h";h'5mHnHu#jh";h'5UmHnHujh";h'5Uj,h";h'5U*R T 12opX'(j23mn !  ./0]^lmnFGUVW$%&XYghij h'Uj h'Uj h'Uj h'Uj0 h'Ujh'UjHh'Ujh'Uj`h'Uh'jh'Ujh'U2 !/01[\jkl,-.Z[ijku&>Obtv h'>* h'5\jh'Uj,h'Uj h'UjD h'Uj h'Uj\ h'Uj h'Uh'jh'Ujt h'U8/0lm1O 3tu & F & F$a$ !%&?(o ! & F & F0LMNObcx  "Muv'( & F & F$a$8\^`b  !!! !N! ! T!$ !a$ ! !   4 6 J L N X Z b d x z | !! !!!!!P!R!f!ڹڮڣژڈjh'CJUmHnHujh'Ujbh'Ujh'Ujvh'Ujh'Ujh'Uh'jh'UmHnHujh'Ujh'U3f!h!j!t!v!!!!!" " """"""""""""# # ##J#^#############4$6$J$L$N$P$Z$b$d$$$$$$ڹڴڴڴکޠڕޠڊjh'Ujh'Uh'mHnHuj&h'U h'>*jh'Uj:h'Ujh'Uh'jh'UmHnHujh'UjNh'U6N!x!z!|!!""""""""####$ %8%:%^%%#&&&' @ & F @ $a$ !$$$$$ %:%*+-+3+4+>+?+, , ,(,*,>,@,B,L,N,^,`,t,v,x,,,,,,,,,,,,,,,,,,,-- --- -"-6-ݻݰݥݚݏjh'Uj`h'Ujh'Ujth'Ujh'Ujh'U h'>* h'5\h'jh'Uh'mHnHujh'UmHnHu6'e''''' ('(((3(r(() ))&)<)a))))`*** & F @ & F @ & F @ & F @  @ & F @ ***++-+P,R,H-J-..<.////R0T000111  @ T P T P $ @ a$ @ & F @ 6-8-:-D-F-h-j-~--------------......<.T.V.r.t.v............... / ////./0/ڹڴکڞړڈjh'Uj h'Ujh'Uj$h'U h'>*jh'Uj8h'Ujh'Uh'jh'UmHnHujh'UjLh'U50/D/F/H/R/T/v/x/////////////// 0 0000*0,0@0B0D0N0P0n0p00000000000000000011$1&1j2h'Ujh'UjFh'Ujh'UjZh'Ujh'Ujnh'Ujh'UmHnHujh'Ujh'Uh'8&1:1<1>1H1J1X1Z1n1p1r1|1~11111111112 22 2"2,2.2\2^2r2t2v2222222222222223 3 3"36383:3j"h'Ujl"h'Uj!h'Uj!h'Uj !h'Uj h'U h'>*j h'Ujh'UmHnHujh'Ujh'Uh'6102222233X4Z4555566P7R777T8V8p88t999  T P  @ T P T P:3D3F333333333333333334444 40424F4H4J4T4V44444444555d5f5555555555555 h'>*j&h'Uj&h'Uj%h'Uj0%h'Uj$h'UjD$h'Uj#h'UjX#h'Uh'jh'Ujh'UmHnHu65666:6<6X6Z6\6p6r66666666666667 7 777(7*7>7@7B7L7N7r7t7777777777777788j6*h'Uj)h'UjJ)h'Uj(h'Ujh'UmHnHuj^(h'Uj'h'Ujt'h'Ujh'Uj'h'Uh'3888"8$8,8.8B8D8F8P8R8V8p88888888888888899(9*9,96989L9N9b9d9f9p9r999999999999:ڿڴکڞړڌ h'5\jp-h'Uj,h'Uj,h'Uj,h'Uj+h'U h'>*j"+h'Uh'jh'UmHnHujh'Uj*h'U599Z:\:::;;j;l;;;Z<\<<<&=(=<=>===*>  @ p P p P  @ T P T P$ T Pa$:::::2:4:H:J:L:V:X:::::::::::::::;;; ;; ;";,;.;B;D;X;Z;\;f;h;n;p;;;;;;;;;;ڽڲڧڜڑچj 1h'Uj0h'Uj40h'Uj/h'UjH/h'Uj.h'U h'5\j\.h'Uh'jh'UmHnHujh'Uj-h'U4;;;;;;<<<<<2<4<H<J<L<V<X<^<`<t<v<x<<<<<<<<<<<<<<<<<<===="=$=&=(=<=>=b=d=x=z=|====jZ4h'U h'5\j3h'Ujn3h'Uj2h'Uj2h'Uj 2h'Uj1h'Uh'jh'UmHnHujh'U9==============>>>>>&>(>.>0>D>F>H>R>T>h>j>~>>>>>>>>>>>>??2?4?6?@?B?^?`?b????j 8h'Uj7h'Uj7h'Uj6h'Uj26h'Uj5h'UjF5h'Ujh'UmHnHuj4h'Uh'jh'U6*>,>>>j?l???@@n@p@AA@ABAAAZB\BCCCC ,P!  @ p P p P????????????@@@@&@(@*@4@6@F@H@\@^@`@j@l@@@@@@@@@@@@@@@@@@AA AA@ABAVAXAlAڽڲڧڜڑjD;h'Uj:h'UjX:h'Uj9h'Ujl9h'U h'5\j8h'Uh'jh'UmHnHujh'Uj8h'U5lAnApAzA|AAAAAAAAAAAAABB2B4BHBJBLBVBXBBBBBBBBBBC C CCCJCLC`CbCdCnCpCCCCCCCC"D$Dڹڮڣژڍj>h'Uj~>h'Uj>h'Uj=h'Uj=h'Uj<h'Uj0<h'Uh'jh'UmHnHujh'Uj;h'U7CCCCJDLDDD6E8E|E~EEEFFFFFGGBHDH p P p@   @ p P$ p Pa$  p P$D8D:DUrUUUUUVVVV V!V"V#V$V%V&V'V(V)V p P p@ )V*V+V,V-V.V/V0V1VNVdVeVVVVVVVV p@ &d (d P R  p@ $d &d N P  p@  $ p@ a$ p@  p PVVVVWIWJWKWLWMWNW\W]WWWWWXX]X p@ &d (d P R  p@ $d &d N P  p@  p@ &d (d P R ]XmXnXXXXY0Y1YxYYYYZZVZZZ[[[[[[\ $ p@ a$ p@  $ p@ a$ p@ ZZZZZ*[,[@[B[D[F[[[[[[[[[[[[[ \ \\\\\&\N\P\T\V\j\l\n\p\r\z\|\\\\\\\\\\\\\ڻڰڠڠڕڊjKh'UjKh'Ujh'CJUmHnHujJh'Uj Jh'Uh'mHnHujIh'Uh'jh'UmHnHujh'Uj0Ih'U4\\N\R\\\] ]d]f]h]j]l]n]p]r]|] ^^^^z_|_DF hp@ , hp@ , hp@  p@ \\\\\\\\\\\\\\]] ]]"]$]&](]*]2]4]:]<]P]R]T]V]X]`]b]r]z] ^^^^^^^^^^^^^_____$_ѻѰѠѠѕъjXNh'UjMh'Ujh'CJUmHnHujhMh'UjLh'UjxLh'Uh'h'mHnHujh'UmHnHujh'UjLh'U6$_&_(_*_,_@_B_D_N_P_R_T_h_j_l_v_x_~_____________________` 246@BϰjRh'UjQh'UUj"Qh'UjPh'Uh'mHnHuj4Ph'UjOh'Ujh'UmHnHujDOh'Uh'jh'UjNh'U3TEXT        FORMTEXT        FORMTEXT  3      FORMCHECKBOX   FORMCHECKBOX   FORMTEXT        FORMTEXT        UNIVERSAL SHELTERED WORKSHOP Training Plan Objective Name  FORMTEXT       Date FORMTEXT       Long Range Goal #  FORMTEXT        FORMTEXT       Present Level/Baseline  FORMTEXT       Criterion for Change  FORMTEXT       Training Days/ Times MON FORMCHECKBOX  TUES FORMCHECKBOX  WED FORMCHECKBOX  THUR FORMCHECKBOX  FRI FORMCHECKBOX  Data Days/Times MON FORMCHECKBOX  TUES FORMCHECKBOX  WED FORMCHECKBOX  THUR FORMCHECKBOX  FRI FORMCHECKBOX  Implementation Date  FORMTEXT       Target Date  FORMTEXT       Completion Date  FORMTEXT       Discontinued  FORMTEXT       Plan/Methodology (Prompts, Schedule of reinforcement, Data collection, Correction procedure, Materials, Generalization strategy.)  FORMTEXT       Trainee Signature ________________________________________________________ Implementers ________________________________________________________ Staff Responsible ________________________________________________________ UNIVERSAL SHELTERED WORKSHOP Summary of Assessments Name  FORMTEXT       Assessed by  FORMTEXT       Date  FORMTEXT       Job Related Skills 1 2 3 4 5  Productivity& & & &  Accuracy& & & & &  Time on Task& & & .  Attendance& & & & .  Punctuality& & & & .  Self-control& & & &  Flexibility& & & & .  Other Work Related Factors Work Habits (motivated to work, follow directions, ect.) Social Skills- FORMTEXT       Safety- FORMTEXT       Hygiene- FORMTEXT       Money/Counting- FORMTEXT       Special Abilities- FORMTEXT       Physical Limitations- FORMTEXT       Disabilities (and cause if known)- FORMTEXT       Adaptive Devices Used- FORMTEXT       Additional Comments- FORMTEXT       Summary of Assessments (cont.) General: Presenting Problem- FORMTEXT       Reason for Assessment- FORMTEXT       Summary of Needed Services- FORMTEXT       Are all needed services available through the program?  FORMTEXT       If no, what recommendations can be made for possible ways to meet those needs? FORMTEXT       What, if any, additional assessments are needed? FORMTEXT       What, if any, environmental modifications would be needed to serve this individual? FORMTEXT       Rating Scale: Productivity: 1= 0-9% 2= 10-19% 3= 20-29% 4= 30-39% 5= 40% and above Accuracy: 1= below 80% 2= 80-84% 3= 85-89% 4= 90-95% 5= 96-100% Time on Task 1= below 80% 2= 80-84% 3= 85-89% 4= 90-95% 5= 96-100% Attendance: 1= below 80% 2= 80-84% 3= 85-89% 4= 90-95% 5= 96-100% Punctuality: 1= below 80% 2= 80-84% 3= 85-89% 4= 90-95% 5= 96-100% Self-control: 1=4 or more occurrences/week 2= 3 3= 2 4= 1 5= 0 Flexibility: 1= below 80% 2= 80-84% 3= 85-89% 4= 90-95% 5= 96-100% UNIVERSAL SHELTERED WORKSHOP Trainee Follow-up Form Name  FORMTEXT       30-Day (Date)  FORMTEXT       Work Rate  FORMTEXT       Accuracy  FORMTEXT       Time on Task  FORMTEXT       Behavioral (report from workshop)  FORMTEXT       60-Day (Date)  FORMTEXT       Work Rate  FORMTEXT       BHJ^`bdfnpvx "jTUh'UjTh'Ujh'CJUmHnHujdTh'UjSh'UjvSh'UjSh'Uh'mHnHujh'UmHnHujRh'Ujh'Uh'2F $^lnp  p@  $ p@ a$ p@  p@ , hp@ ,246@BDFZ\^hjRTprt~jYh'UjYh'UjXh'Uj"Xh'UjWh'Uj4Wh'UjVh'UjDVh'Ujh'UmHnHujUh'Uh'jh'U3 "$&,.:<2 p P p@  \^z|~ &(*XZnpr|~(*,68prj]h'Uj8]h'Uj\h'Ujh'UmHnHujH\h'Uj[h'Uj\[h'UjZh'UjpZh'UjYh'Uh'jh'U3  *,@BDNP`bvxz >@hj LN 468BDZj`h'Ujh'CJUmHnHuj_h'Uj_h'Uj^h'U h'5\j(^h'Uh'jh'UmHnHujh'U; RT >Fhp & F p@  p@  $ p@ a$ p@  p P&LPRFJ XZ v & F p@  p@ Z\prt~02FHJTV NPdfhrtjch'UjPch'Ujbh'Uj`bh'Ujah'Ujpah'Uj`h'Ujh'UmHnHuj`h'Uh'jh'U7vx  pt,.F b & F p@  $ p@ a$ p@  HJ^`bln(*jl 0`lnjgh'Ujfh'Uj fh'Ujeh'Uj0eh'Ujdh'Ujh'UmHnHuj@dh'Ujh'U h'5\h'9bcij*,0 p@  p P p@ 0^`46NPRTVXZPR p@  $ p@ a$n "$&02`bvxz&(<>@JLjjh'UjXjh'Ujih'Ujhih'Ujhh'Ujxhh'Ujhh'Ujh'UmHnHujh'Ujgh'Uh'7 Accuracy  FORMTEXT       Time on Task  FORMTEXT       Behavioral (report from workshop)  FORMTEXT       90-Day (Date)  FORMTEXT       Work Rate  FORMTEXT       Accuracy  FORMTEXT       Time on Task  FORMTEXT       Behavioral (report from workshop)  FORMTEXT       UNIVERSAL SHELTERED WORKSHOP Individual s Rights Rights of All Individuals Ensure That: You have the right to be informed of your rights and responsibilities and the rules and conduct you should follow. You have the right to be informed in writing and if necessary verbally explained, what services are available from the workshop. Most of these services are covered by your government funding sources, if they are not, you will be informed of what fees will be charged to you. You have the right to gave your own program plan and to have the plan explained to you. You have the right to participate in the planning of your program. This program plan will tell you how the staff here expected to help. You have the right to refuse a program plan. You have the right to meet with the staff to talk about your program plan. You have the right to participate in research projects, but only if you or your parent/guardian gives written consent. You have the right to withdraw from the research project at any time. You have the right to stay in the program except if it is felt you should be transferred or discharged for medical reasons, for your welfare or that of others, or nonpayment of agreed upon fees for services provided by the workshop (except as prohibited by the Title XIX program). You have the right to be safe from harm. You should not be neglected, threatened, insulted or physically hurt. You have the right to be free from chemical or physical restraints. This right can be limited if you, your parents and/or guardian agree in writing that restraints are needed in an emergency to protect you and/or the people around you from injury. You have the rights to have information about you kept private. Information about you may be given to others outside this agency if so required by law or a court order, and/or parent/guardian give written consent. You have the right to be treated with dignity and respect, and to have respect for your property. You have the right to complain if you think your rights have been violated. What To Do If You Feel Your Rights Have Been Violated: If you feel your rights have been violated, you should follow the procedure scribed by the policy manual. If you need assistance with this go to your program specialist, social worker, center coordinator, or any other staff member whom you are comfortable with and who was not involved in the incident. If you are not satisfied with results of following the procedure, or if you still feel you need advice concerning your legal rights, you can get further help at Missouri Advocacy. The phone number is 1-800-329-8667. (*>@BLNxzJL`bdnp @BVXZdfjnh'Ujnh'Ujmh'Uj(mh'Ujlh'Uj8lh'Ujkh'Ujh'UmHnHujHkh'Ujh'Uh'U6 "rthjDF| & F p@  $ p@ a$ p@  p@ FD \ ^  h'>* h'5\h'jh'UmHnHujh'U |RbRz>F \ ^  p@  & F p@  1h/ =!"#$%xDText177xDText178xDText179xDText180xDText181xDText182tDText7tDText8tDText9vDText10vDText11vDText13vDText12tDeCheck1tDeCheck1tDeCheck1tDeCheck1tDeCheck1tDeCheck1tDeCheck1tDeCheck1tDeCheck1tDeCheck1tDeCheck1tDeCheck1tDeCheck1tDeCheck1tDeCheck1tDeCheck1tDeCheck1tDeCheck1tDeCheck1tDeCheck1vDText14vDText15vDText16vDText17vDText18vDText19vDText20vDText21vDText22vDText23vDText24vDText25vDText26vDText27vDText28vDText29vDText30vDText31vDText32vDText33vDText34vDText35vDText36vDText37tDeCheck2tDeCheck3vDText38vDText39vDText40vDText41vDText44vDText43vDText42vDText46vDText45vDText49vDText48vDText47vDText50vDText51vDText53vDText52vDText56vDText55vDText54vDText59vDText58vDText57tDeCheck4tDeCheck5tDeCheck7tDeCheck6tDeCheck8tDeCheck9vDeCheck10vDText62vDText61vDText60vDText64vDText63vDText65vDText66vDText68vDText67vDText70vDText69vDText71vDText73vDText72vDText74vDText75vDText78vDText76vDText79vDText77vDText74vDText75vDText78vDText76vDText79vDText77vDText74vDText75vDText78vDText76vDText79vDText77vDText80vDeCheck12vDeCheck11vDText82vDText81vDText84vDText83vDText87vDText86vDText85vDText96vDText88vDText91vDText97vDText93vDText98vDText95vDText99xDText100xDText101xDText102xDText103xDText104xDText106xDText105vDeCheck13vDeCheck14vDeCheck15xDText107vDeCheck16vDeCheck17vDeCheck18vDeCheck19xDText108xDText109vDeCheck20vDeCheck21xDText110xDText111xDText112xDText113xDText114xDText115xDText116xDText119xDText117xDText120xDText118xDText121xDText122vDeCheck22vDeCheck23xDText125xDText126xDText123vDeCheck24vDeCheck25xDText127xDText128xDText124vDeCheck26vDeCheck27xDText129xDText130xDText131xDText132xDText133xDText134xDText135xDText136vDeCheck28vDeCheck29vDeCheck30vDeCheck31vDeCheck32vDeCheck33vDeCheck34vDeCheck35vDeCheck36vDeCheck37xDText137xDText138xDText139xDText140xDText141xDText142xDText143xDText144xDText145xDText146xDText147xDText148xDText149xDText150xDText151xDText152xDText153xDText154xDText155xDText156xDText157xDText158xDText159xDText160xDText161xDText162xDText163xDText164xDText165xDText166xDText167xDText168xDText169xDText170xDText171xDText172xDText173xDText174xDText175xDText176@@@ NormalCJ_HaJmH sH tH @@@ Heading 1$$@&a$5\@@@ Heading 2$ @ @&>*B@B Heading 3$ @ @&5\DAD Default Paragraph FontViV  Table Normal :V 44 la (k(No List 6>@6 Title$a$ 5>*\V !"#$%&'()*9:;<=>?@ABCDEFGHIJKl;[23lm12opX'(j23mn/0lm1O 3 t u % & ? ( o  0 L M N O b c x  "Muv'(YZ[\]z EFmn DYZ[rg#e '(3r &<a`-hiIJ^ijXY  l m !!3!!!!!/"0"j"k"x""",#6#7#m#n#######($)$m$n$$$$$$$"%#%U%V%%%%%:&;&B&C&w&x&&&&&''m'n'''(('(((8(e(f(((((((')()B)C))))**a*b****u+,,,,,K-L-------.4.[.\.].^..../2/3/v//////V0W0j0k0u0v0w0x0000001S1T11112`2a2b2c2d2e2f2g2h2222222d3e3f34444F4|4}4~44444&5\5]5^5_5`5a5b5c5d5e5f5g5h5i5j5k5l5m5n5o5p5q5555558696:6;6<6=6>6?6@666666666666=7U7V7777788\8p8q8888#9M9N9k99999::3:4:N:O:g:i::::::::::::::E;;;;;;b<c<<<<<<<<<<<<<==;=<=v=w=x=====R>S>>>??1?2?]?^???@@$@%@&@r@@ A A AAAAAAAAAAAA5ALAMAAAAAAAABBB*B.B@BDBWB[BnBrBBBBBBBBCC C!C>C?CcCdCCCCCCCDDDDEDdDeDnDoDDDDDDDCEEEEEE.FYFZFhFiFFFGGpGqGGG H!HtHuHHHHHHHHHHHHHHHII)I*IPIQIyIzIIIIIJJJ J J J J4J5J]J^JJJJJJJJJJJJKKAKBKkKlKKKKKKKLL)L*LLMNNNOOPNQFRS~SSST VV000000000000000000000000000000000000 0000(000 0000000000000000000000000000000000000000000000000000m0m0m0m0m0m0m0m0m 0m 0m 0m 0m 0m 0m0m 0m 0u m 0u m 0u m0m 0m 0& m 0& m 0& m 0& m0m 0m 0 m 0 m 0 m 0 m0m 0m 0 m 0 m0m0m0m0m0m0m0m0m00 0 0 0 0 0 0  0  0  0  0  0 0 0 0  0  0  0  0  0  0 0 0 0 0 0 0 0 0 0 0 00]0]0]0]0]0]0]0]0]0]0]0]0]0]0]0]0]0]0]0]0]0]0]0]0]0]0]0]0]0]0]0]0]0]0]0]0]00g0g0g 0 0 000g 0 0 000g 0 000g 0( 0( 0(0(0g 0  0  0  0 0 0g 0 0 0 0000(0000000(00J0J0J0J0J0J0J0J0J0J(000000000000(00!0!0!0!0!0!0!0!(00k"0k"0k"00,#0,#0,#(0,#0n#0n#0n#0n#0n#0n#0n#0n#0n#0n#0n#0n#0n#(0,#0$0$0$0$0$0$0$0$0$0$0$(0,#0;&0;&0;&0;&0;&(0,#0&0&0&0&0&0&0&0&0&00((0(0((0((0((0((0((0((0((0((0((0((0((0((0((0(((0(0)0)0)0)0)0)0) 0) 0) 0)0)0)0)0)0)0)0)0)0)0)0)0)00.0.0.0.0.0.0.0.0.0.0.0.0.0.0.0.0.0.0.0.0.0.0.0.0.0.0.0.0.0.0.0.0.0.0.0.0.0.0.0.0.0.0.0.0.00h20h20h20h20h20h20h20h20h20h20h20h20h20h20h20h20h20h20h20h20h20h20h20h20h20h20h20h20h20h20h20h20h20h20h20h20h20h20h20h20h20h20h200q50q50q50q50q50q50q50q50q50q50q50q50q50q50q50q50q50q50q50q50q50q50q50q50q50q50q50q50q50q50q50q50q50q50q50q50q50q50q50q50q5000N90N90N90N90N90N90N90N90N90N90N90N90N90N90N90N90N90N90N90N90N90N90N90N90N90N90N90N90N90N90N90N90N90N90N90N90N90N90N90N90N90N90N90N9000<0<0<0<0<0<0<0<0<0<0<0<0<0<0<0<0<0<0<0<0<0<0<0<0<0<0<0<0<0<0<0<0<0<0<0<0<0<0<0<0<0<0<00A0A0A0A0A0A 0A0A0A0A0A0A0A0A0A0A0A0A0A0A0A0A0A 0A0A0A0A0A0A0A0A0A0A0A0A0A0A0A0A0A0A0A0A0A0A0A0A 0A0A0A0A0A0A0A0A0A0A0A0A0A0A0A0A0A0A0A0A0A0A0A0A0A0A0A0A0A0A0A0A0A0A0A0A0A0A0A0A0A0A0A0A00H0H0H0H0H0H0H0H0H0H0H0H0H0H0H0H0H0H0H0H0H0H0H0H0H0H0H0H0H0H0H0H0H0H0H0H0H0H0H0H0H0H0H0H0H00K0K0K0K 0K 0K 0K 0K 0K 0K 0K 0K 0K 0 K 0 K 0 K 0 K0000 f!$6-0/&1:358:;=?lA$DGMZ\$_BZn^ 04578=>@CDEGHIKLMOPRSU\^_moqruwzR N!'*19*>CDHNP&T)VV]X\F vb0|^ 1369:;<?ABFJNQTVWXYZ[]npstvxy^ 2KWjlx(9;GY[gpr~*0Zj/]mFV%Xh 0[k-Zj&,1=CYekxEQWs&1Q]e3?ET`fo{#)5AGjz *0:FLUagw(4:DPVnz   , 2 = I O X d j !!!>!N!]!m!x!!!!!!!!!!!!" ""'"-"?"K"Q"V"b"h"""""""""""""#$#*#<#H#N#Y#e#k##############$ $$ $&$<$H$N$Y$e$k$o${$$$$$$$$$$$$$%%% %$%0%6%A%M%S%W%c%i%t%%%%%%%%%%&&&&&2&8&H&T&Z&c&o&u&&&&&&&&&&&&& '''1'='C'Y'e'k''''''''''(((Q(](c((((((())%).):)@)Z)f)l))))))**b*r****,,, -L-\-------....3/C/22299999999::+:1:::F:L:j:v:}::::::::::::::::;;;;;;;;;;;;;; <<<&<(<8<:<F<L<N<Z<`<d<p<w<{<<<<<<<<<< ==='=3=9=N=Z=`=b=n=t==========>>$>*>:>?>O>n>~>>>>>>>>>>>>?)?/?I?U?[?x???@@"@RA^AdAtAAAAAABBC CCC*C6C Y !?!^!y!!!!!"@"W"""""#=#Z######$%%%&'&I&d&&&&& '2'Z'''' (R((()/)[)))*c**,,M----.4/2999 :;:k::::::;;;;;<<)<;<O<e<|<<<<=(=O=c====>>+>@>o>>>>>>?J?y?@SAuAAB C+CPCxCCCD1DDDD/EEEFFI=IfIIII!JJJtJJJK.KXKKKV  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~k:Zq1k-DlX2fFg*H{1Mh;W 3 P k !!O!n!!!!! "."R"i"""""+#O#l##### $'$%%%&9&[&v&&&&&'D'l''''(d(((&)A)m)))*s**, -]---..D/299:2:M:~::::::;;;;;<'<9<M<a<x<<<<< =:=a=u====>%>;>P>>>>>>>0?\??#@eAAACC=CbCCCCDCDDDDAEEEXF(IOIxIIIJ3J\JJJJK@KjKKKV'D#ED#Ft#G,|HI8Jt{K#"L#"MN$OdPQRDSTUVDWXYt\ Z\ [\ \4] ]t] ^] _] `4^ abcDdefgDhij Q Q [ 009O!O!V!o'o'x'..////(/,/e/e/o///////888<=<=A=V      "!#%$& Z a a 8??U!Z!Z!w'~'~'.. //&/*/1/1/n/u/u///////888@=F=F=V    "!#%$&9'*urn:schemas-microsoft-com:office:smarttagsplace=&*urn:schemas-microsoft-com:office:smarttags PlaceName=$*urn:schemas-microsoft-com:office:smarttags PlaceType8*urn:schemas-microsoft-com:office:smarttagsCity9*urn:schemas-microsoft-com:office:smarttagsState;*urn:schemas-microsoft-com:office:smarttagsaddress:*urn:schemas-microsoft-com:office:smarttagsStreet>*urn:schemas-microsoft-com:office:smarttags PostalCode '&&$'&$'&$''&$'''&$''&$'&$./BB_H`HV|~`i#/ym n!!,,,,=-@-//0 0+0/0M0U0W0b0l0s0001"1J1Q1111122@2T2G4K4s4z44444'5+5S5Z59:J;R;.@:@r@~@@@BBEDcD~EEEE/F4FMMIOPOV33333333333333333333333333333333333333333333333;3 3 u & ? o c o[s3r <i m !0"k"",#7#n###)$o$$$%''q))--99:U:^??MABEDDI*II JJJKKU VVVUniversal Workshop Inc.Universal Workshop Inc.Universal Workshop Inc.Universal Workshop Inc.Universal Workshop Inc.Universal Workshop Inc.Universal Workshop Inc.Universal Workshop Inc.Universal Workshop Inc.jeremiah 9XZ\>J=z~:+ڊz$-֜qU1D\-?y bElUjMEcIS" Rlag| )hZq"g88^8`o(.^`. L ^ `L.  ^ `.xx^x`.HLH^H`L.^`.^`.L^`L.  ^ `o(.xx^x`.HLH^H`L.^`.^`.L^`L.^`.X X ^X `.(#L(#^(#`L.^`o(.^`.pLp^p`L.@ @ ^@ `.^`.L^`L.^`.^`.PLP^P`L.^`o(.^`.pLp^p`L.@ @ ^@ `.^`.L^`L.^`.^`.PLP^P`L.  ^ `o(.xx^x`.HLH^H`L.^`.^`.L^`L.^`.X X ^X `.(#L(#^(#`L.88^8`o(.^`. L ^ `L.  ^ `.xx^x`.HLH^H`L.^`.^`.L^`L.  ^ `o(.xx^x`.HLH^H`L.^`.^`.L^`L.^`.X X ^X `.(#L(#^(#`L.^`o(.^`o(.pLp^p`L.@ @ ^@ `.^`.L^`L.^`.^`.PLP^P`L.  ^ `o(.  ^ `.xLx^x`L.HH^H`.^`.L^`L.^`.^`.X LX ^X `L.  ^ `o(.xx^x`.HLH^H`L.^`.^`.L^`L.^`.X X ^X `.(#L(#^(#`L.  ^ `o(.xx^x`.HLH^H`L.^`.^`.L^`L.^`.X X ^X `.(#L(#^(#`L.  ^ `o(.xx^x`.HLH^H`L.^`.^`.L^`L.^`.X X ^X `.(#L(#^(#`L. bEU19z$-\>cISag-?)hZqjM~:+                                   |"}        >        @pp         We       4J        4x                  6U        `S";'@rtrr@@@@@ @!@"@#@$@%@&@(@)@*@+@-@.@2@3@9@:@;@<@=@>@?@@_A_B_D_E_F_H_I_JVPP P P@PP P$PL@P,P.P0P2P4P6P8P:P<P>P@PDPFPHP@PLP@PRP@PZP\P^PPPPP@PPPPP@PPPUnknownGz Times New Roman5Symbol3& z Arial"qhCqFv 6I+ 6I+Y24UU 3QH(?`SCLIENT PERSONAL DATA SHEETUniversal Workshop Inc.jeremiah<         Oh+'0 $0 L X dpxCLIENT PERSONAL DATA SHEETLIEUniversal Workshop Inc.nivnivNormala jeremiah Wo7reMicrosoft Word 10.0@ҏ.$@Z@N!+7 6I՜.+,0 hp  Universal Workshop Inc.+UA CLIENT PERSONAL DATA SHEET Title  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~      !"#$%&')*+,-./1234567<Root Entry F0Hy,7>Data o1TablefWordDocument"SummaryInformation((DocumentSummaryInformation80CompObjj  FMicrosoft Word Document MSWordDocWord.Document.89q