The madison social relationship inventory



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Other Information

Record other information needed to secure a reasonable understanding of the current after school-weekend life of the student.


The task now is to determine if current after school-weekend realities are in reasonable accordance with the values presented. The strategy offered is to delineate the time segments judged by the IEP team and significant others to be in need of the most attention; and then compare the values to the realities in each. In most instances the after school and the Saturday morning time segments are the most problematic and therefore are given priority over others. The forms, etc. necessary to address Time Segment #1 and one additional segment are provided. Users are encouraged to adapt that presented to address other time segments.

The School
Does the student attend his/her home school; i.e., the school she/he would probably attend if not disabled?
Yes
No

If "No," does the fact that the student does not attend his/her home school have an effect on her/his after school-weekend social life?


Yes
No

If "Yes," report how the after school-weekend social life of the student is affected by attending a non-home school.


The student does not attend school with nondisabled peers who live near him. This makes it extremely difficult to establish relationships at school and then arrange for them to be expressed after school and during weekends.




Time Segment #1



Day
M T W T F All School Days
Time
From ____ To ______


Environments

Record the environments in which the student typically functions in Time Segment #1 or examine the Current After School-Weekend Chart.



Is the array of environments in which the student functions during Time Segment #1 acceptable?


Yes
No

If "Yes," report why the array of environments in which the student functions during Time Segment #1 is acceptable.



If "No," report why the array of environments in which the student functions during Time Segment #1 is unacceptable.

Are there environments in which the student should function during Time Segment #1, but does not?


Yes
No

If "Yes," report the environments in which the student should function during Time Segment #1 and why.





Activities

Record the activities in which the student is involved during Time Segment #1 or examine the Current After School-Weekend Chart.


Is the array of activities in which the student participates during Time Segment #1 acceptable?


Yes
No

If "Yes," report why the array of activities in which the student participates during Time Segment #1 is acceptable.



If "No," report why the array of activities in which the student participates during Time Segment #1 is unacceptable.

Are there activities in which the student could or should participate during Time Segment #1, but does not?


Yes
No

If "Yes," report the activities in which the student could or should participate during Time Segment #1 and why.




Time

Are the amounts of time the student participates in each activity during Time Segment #1 acceptable?


Yes
No

If "Yes," report why the amounts of time the student participates in each activity during Time Segment #1 are acceptable.



If "No," report why the amounts of time the student participates in an activity during Time Segment #1 are unacceptable.



Persons With Whom The Student Interacts

Record the persons with whom the student interacts during Time Segment #1 or examine the Current After School-Weekend Chart.


Schoolmates with disabilities
Schoolmates without disabilities
Mother
Father
Brother
Sister
Grandparent
Cousin
Neighborhood peers
Babysitter
Personal attendant
Supportive companion


Is the array of persons with whom the student interacts during Time Segment #1 acceptable?


Yes
No

If "Yes," record why the array of persons with whom the student interacts during Time Segment #1 is acceptable.



If "No," record why the array of persons with whom the student interacts during Time Segment #1 is unacceptable.

Are there persons with whom the student should interact during Time Segment #1, but does not?


Yes
No

If "Yes," report the persons with whom the student should interact during Time Segment #1 and why.




Supervision

Record the persons responsible for supervising the student during Time Segment #1.


Adult activity leader
Educational assistant
Special education teacher
Schoolmates without disabilities
Personal attendant
Volunteer
Parent


Are the persons responsible for supervising the student during Time Segment #1 acceptable?


Yes
No

If "Yes," report why the persons responsible for supervising the student during Time Segment #1 are acceptable.



If "No," report why the persons responsible for supervising the student during Time Segment #1 are unacceptable.

Report those persons who should be responsible for supervising the student during Time Segment #1, but are not.
Adult activity leader
Schoolmates without disabilities
A supportive companion



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