Activity Assessment Questionnaire

ACTIVITY ASSESSMENT QUESTIONNAIRE

INSTRUCTIONS: Answer the following questions for a specific activity. Use the responses to help determine whether a proposed activity is meaningful and appropriate for development of a travel plan.

SETTING	.
ACTIVITY	.
DAY	.
TIME OF DAY	.

Is the activity one requested or recommended by the family?	YES	NO
Is the activity valued by the family?	YES	NO
Is the activity preferred by the person who would participate?	YES	NO
Is the activity one in which other family members currently participate?	YES	NO
Is the activity likely to become part of the person's regular routine or schedule?	YES	NO
Is the activity age appropriate?	YES	NO
Is the activity located where nondisabled peers are likely to be present?	YES	NO
Is the activity likely to support opportunities for social interactions with nondisabled peers?	YES	NO
Is the activity one the person may be able to do alone?	YES	NO
Is the activity taking place when and where assistance will always be available?	YES	NO
Could opportunities to support communication with nondisabled peers occur?	YES	NO
Could opportunities for the person to make choices occur during the activity sequence?	YES	NO
Could opportunities to develop routes for travel exist either going to or coming from the activity?	YES	NO
Could opportunities to develop movement patterns for travel exist within the activity sequence?	YES	NO
Could other opportunities for mobility exist in or around the location of the activity?	YES	NO
Could opportunities for the person to actively participate exist throughout the whole activity sequence?	YES	NO
Could the opportunity exist for the person to learn or practice skills during the activity sequence?	YES	NO
Could skills learned during this activity be expanded or practiced during other activities?	YES	NO
Could scheduling participation on a regular basis be an issue for this activity?	YES	NO
Could the person's safety be an issue at any point during this activity?	YES	NO
Could time constraints be an issue at any point in the completion of this activity?	YES	NO
Could supervision of the person be an issue at any point in this activity?	YES	NO
Could the person's behavior be an issue at any point in this activity?	YES	NO