Participant Questionnaire

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Please correct the field(s) marked in red below:

This questionnaire will assist the Inclusion Services in determining the proper accommodation for the participant in the most inclusive setting.  Information will only be shared with staff who will be working directly with the participant.  Your cooperation is appreciated as the City is committed to providing a positive and enjoyable experience.


 
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IF APPLICABLE, PLEASE ATTACH A COPY OF THE PARTICIPANT’S CURRENT INDIVIDUALIZED EDUCATION PROGRAM (IEP):


 Level of Supervision (please check all that apply):
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Level of Supervision (please check all that apply):
Communication (please check all that apply):
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Communication (please check all that apply):
Receptive/Listening Skills
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Receptive/Listening Skills
Attention Span (Please check all that apply):
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Attention Span (Please check all that apply):
Social Skills (Please check all that apply):
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Social Skills (Please check all that apply):
Emotional/Behavioral Tendencies (please check all that apply)
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Emotional/Behavioral Tendencies (please check all that apply)
Physical Activity Level (Please check all that apply):
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Physical Activity Level (Please check all that apply):
Fine Motor Skills (Please check all that apply):
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Fine Motor Skills (Please check all that apply):
Gross Motor Skills (Please check all that apply):
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Gross Motor Skills (Please check all that apply):
Eating/Drinking (Please check all that apply):
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Eating/Drinking (Please check all that apply):

* Personal Care (Please check all that apply) MUST BE FILLED OUT
** We do not toilet participants in our programs

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* Personal Care (Please check all that apply) MUST BE FILLED OUT ** We do not toilet participants in our programs
Mobility for Wheelchair, Walker, or Crutch
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Mobility for Wheelchair, Walker, or Crutch
Field Trips (please check all that apply)
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Field Trips (please check all that apply)
Water Skills (please check all that apply)
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Water Skills (please check all that apply)
What are the participant’s common behaviors displayed at school or in the home setting (positive and negative)?
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What triggers (if any) contribute towards anxiety and/or acting out behaviors (i.e. hypersensitive to touch, loud noises, losing at a game, etc.)? (If none, please leave N/A)
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Describe in detail any acting out behaviors we should be aware of (i.e. yelling, aggressive, quiet, shutdown, swearing, running away, etc.)? (If none, please leave N/A)

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Should the participant become agitated/irate, what calming or de-escalating activities help the participant (i.e. using words, time out, rub back, etc.)?
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Describe how the participant does in group settings, small or large?
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Please list any suggestions for easing transitions or changes in routine:
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What techniques help motivate, re-direct and/or help maintain the participant’s focus?
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How does the participant learn best (i.e. visual, auditory, hands on, etc.)?
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What are the participant’s three favorite indoor activities  (Example: board games, video games, arts & crafts, music, dance, etc.)?
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What are the participant’s three favorite outdoor activities (Example:  hiking, sports, swimming, active group games, etc.)?
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Describe the participant’s awareness of danger or impulse control
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List any other helpful information regarding the participant we should know
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