Author: None

Student Name:_____________________________________ Date:_____________________________
Staff Supporting Student:_____________________________ Job Site:___________________________

I= Independent P=Physical Prompt V=Verbal Prompt G=Gesture Prompt T= Text Prompt

Appearance:	Appropriate/clean clothing / I P V G T	Hair clean/combed / I P V G T	Hands and Nails Clean / I P V G T
Prepared to leave:	Coat/needed supplies ready / I P V G T	At Bus on Time / I P V G T	Left Location appropriately / I P V G T
Safety:	Followed Safety Signs / I P V G T	Performed job safely / I P V G T	Used Transportation Safely / I P V G T
Time:	Time Arrived at Site: / ______________	Total Time on Task: / Work Time____/ On Task_____	Time Left Site: / ______________
Behavior: Manage / Impulsivity	Positive / I P V G T	Respect/Responsibility / I P V G T	Blue Ticket Earned: / Yes or No
Peer Interaction: / Interdependent	Positive / I P V G T	Worked on Relationship w/peer / I P V G T	Peer Name: / __________________

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