SYSTEMS APPROACH TO PLACEMENT (SAP) INTAKE ASSESSMENT AND OUTCOME EVALUATION (IAOE) Dr. Madan M. Kundu and Dr. Chrisann Schiro-Geist (copyright 1993) Rate the client's needs at intake for each item: Rate Placement Outcome Evaluation: NE = Not Eligible for Service 0 = No Service Needed 0 = No Service Received 1 = Minimum Service Needed 1 = Minimum Service Received 2 = Average Service Needed 2 = Average Service Received 3 = More Than Average 3 = More Than Average Service Needed Service Received 4 = Extensive Service Needed 4 = Extensive Service Received Descriptions: Minimum Service (Up to 6 months): examples: medical evaluation, psychological/psychiatric evaluation, vocational evaluation, pair of glasses, orthotic device, simple adaptive equipment, 1-3 counseling and guidance sessions, and/or post-employment service. Average Service (About 1 year): examples: medical evaluation, psychological/psychiatric evaluation, vocational evaluation, 3-6 counseling and guidance sessions, adaptive equipment, and/or client centered placement. More Than Average Service (About 2 years): examples: medical evaluation, vocational evaluation, psychological/psychiatric evaluation, supported employment, on-the-job training, complex adaptive equipment, 6-9 counseling and guidance sessions, and/or client centered/selective placement. Extensive Service (Over 2 years): examples: medical evaluation, psychological/psychiatric evaluation, vocational evaluation, medical treatment and surgery, orthotic/prosthetic evaluation and service, physical and occupational therapy, personal adjustment training, work adjustment training, on-the-job training, skill training, earning a certificate/diploma/college degree, assistive technology, adaptive equipment, and/or selective placement service to persons with traumatic brain injury, spinal cord injury, chronic mental illness, substance abuse, visual impairment or blindness, or hearing impairment or deafness. I. CLIENT SUBSYSTEM 1. Intelligence Testing INTAKE ____________ OUTCOME ____________ 2. Interest Testing INTAKE ____________ OUTCOME ____________ 3. Aptitude Testing INTAKE ____________ OUTCOME ____________ 4. Specific Ability Testing INTAKE ____________ OUTCOME ____________ 5. Vocational Testing INTAKE ____________ OUTCOME ____________ 6. Personality Evaluation INTAKE ____________ OUTCOME ____________ 7. Personal Hygiene INTAKE ____________ OUTCOME ____________ 8. Independent Living Skills INTAKE ____________ OUTCOME ____________ 9. Adjustment to Disability INTAKE ____________ OUTCOME ____________ 10. Communication Skills INTAKE ____________ OUTCOME ____________ 11. Interpersonal Skills INTAKE ____________ OUTCOME ____________ 12. Living Arrangements INTAKE ____________ OUTCOME ____________ 13. Work adjustment Skills INTAKE ____________ OUTCOME ____________ 14. Management of Local Transportation INTAKE ____________ OUTCOME ____________ 15. Level of Motivation INTAKE ____________ OUTCOME ____________ Total Score INTAKE ____________ OUTCOME ____________ II. HEALTH SUBSYSTEM 1. Primary Disability INTAKE ____________ OUTCOME ____________ 2. Secondary Disability INTAKE ____________ OUTCOME ____________ 3. Mental Status INTAKE ____________ OUTCOME ____________ 4. Orthotic Aids (wheelchair, braces, crutches, hearing aids, etc) requirement INTAKE ____________ OUTCOME ____________ 5. Prosthetic Aids requirement INTAKE ____________ OUTCOME ____________ 6. Assistive Technology requirement INTAKE ____________ OUTCOME ____________ Total Score INTAKE ____________ OUTCOME ____________ III. EDUCATION SUBSYSTEM 1. Self-Study Courses INTAKE ____________ OUTCOME ____________ 2. General Education Development (GED) Program INTAKE ____________ OUTCOME ____________ 3. Formal Education Programs (A.A., B.A., M.A., etc.) INTAKE ____________ OUTCOME ____________ 4. Skills Training INTAKE ____________ OUTCOME ____________ 5. On-the-Job Training INTAKE ____________ OUTCOME ____________ 6. Supported Employment Training INTAKE ____________ OUTCOME ____________ Total Score INTAKE ____________ OUTCOME ____________ IV. FAMILY SUBSYSTEM 1. Person with disability's adjustment to the family INTAKE ____________ OUTCOME ____________ 2. Family's adjustment to the person with disability INTAKE ____________ OUTCOME ____________ 3. Communication with family INTAKE ____________ OUTCOME ____________ 4. Adjustment Counseling INTAKE ____________ OUTCOME ____________ 5. Financial Resources INTAKE ____________ OUTCOME ____________ 6. Attendant Care INTAKE ____________ OUTCOME ____________ 7. Child Care INTAKE ____________ OUTCOME ____________ Total Score INTAKE ____________ OUTCOME ____________ V. SOCIAL SUBSYSTEM 1. Determining Language Barriers INTAKE ____________ OUTCOME ____________ 2. Referring a client with language barrier for assistance INTAKE ____________ OUTCOME ____________ 3. Determining Cultural/Ethnic Barriers INTAKE ____________ OUTCOME ____________ 4. Referring a client with cultural/ethnic barrier for assistance INTAKE ____________ OUTCOME ____________ 5. Determining Moral Barriers INTAKE ____________ OUTCOME ____________ 6. Referring a client with moral barrier for assistance INTAKE ____________ OUTCOME ____________ 7. Determining Religious Barriers INTAKE ____________ OUTCOME ____________ 8. Referring a client with religious barrier for assistance INTAKE ____________ OUTCOME ____________ 9. Identifying significant others' attitudes toward the person with a disability INTAKE ____________ OUTCOME ____________ 10. Community resources (support groups, AA, etc.) INTAKE ____________ OUTCOME ____________ Total Score INTAKE ____________ OUTCOME ____________ VI. EMPLOYER SUBSYSTEM 1. Organizational Structure Barriers INTAKE ____________ OUTCOME ____________ 2. Employer Attitudinal barriers INTAKE ____________ OUTCOME ____________ 3. Co-worker attitudes INTAKE ____________ OUTCOME ____________ 4. Union Barriers INTAKE ____________ OUTCOME ____________ 5. Environmental/Architectural Barriers INTAKE ____________ OUTCOME ____________ 6. Job Development Potential INTAKE ____________ OUTCOME ____________ 7. Job Modification/Re-Engineering (Braille typewriter, large print, talking calculator, TTY, TDD, etc.) INTAKE ____________ OUTCOME ____________ 8. Job Analysis INTAKE ____________ OUTCOME ____________ Total Score INTAKE ____________ OUTCOME ____________ II. PLACEMENT PERSONNEL SUBSYSTEM 1. Referral Resources Regarding Placement INTAKE ____________ OUTCOME ____________ 2. Agency Policy Regarding Placement INTAKE ____________ OUTCOME ____________ 3. Agency Resources Regarding Placement INTAKE ____________ OUTCOME ____________ 4. Vocational Counseling and Guidance needs INTAKE ____________ OUTCOME ____________ 5. Job Readiness INTAKE ____________ OUTCOME ____________ 6. Job Seeking/Retention Skills INTAKE ____________ OUTCOME ____________ 7. Counselor's/Placement Specialist's academic preparation, knowledge, experience, and resourcefulness INTAKE ____________ OUTCOME ____________ Total Score INTAKE ____________ OUTCOME ____________ VIII. FUNDING SUBSYSTEM 1. State/Federal Grants in Aid INTAKE ____________ OUTCOME ____________ 2. Basic Education Opportunity Grant (PELL Grant) INTAKE ____________ OUTCOME ____________ 3. Guaranteed Student Loan (G.S.L.) INTAKE ____________ OUTCOME ____________ 4. Supplemental Security Income (SSI)/Medicaid INTAKE ____________ OUTCOME ____________ 5. Social Security Disability Insurance (SSDI)/Medicare INTAKE ____________ OUTCOME ____________ 6. Job Service INTAKE ____________ OUTCOME ____________ 7. General State Aid INTAKE ____________ OUTCOME ____________ 8. Workers' Compensation INTAKE ____________ OUTCOME ____________ 9. State Rehabilitation Services INTAKE ____________ OUTCOME ____________ 10. Private Insurance INTAKE ____________ OUTCOME ____________ 11. Private facilities INTAKE ____________ OUTCOME ____________ 12. Community Resources INTAKE ____________ OUTCOME ____________ 13. Personal/Family Resources INTAKE ____________ OUTCOME ____________ Total Score INTAKE ____________ OUTCOME ____________ INTAKE ASSESSMENT AND OUTCOME EVALUATION SUMMARY OF SCORES I. Client Subsystem Total = _____ Divide by 15 Average = _____ II. Health Subsystem Total = _____ Divide by 6 Average = _____ III. Education Subsystem Total = _____ Divide by 6 Average = _____ IV. Family Subsystem Total = _____ Divide by 7 Average = _____ V. Social Subsystem Total = _____ Divide by 10 Average = _____ VI. Employer Subsystem Total = _____ Divide by 8 Average = _____ VII. Placement Personnel Subsystem Total = _____ Divide by 7 Average = _____ VIII. Funding Subsystem Total = _____ Divide by 13 Average = _____ Total Score I to VIII = _____ Divide by 72 Average = _____