The madison social relationship inventory



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Time Segment #



Day

___ M ____ T ____ W ____ T ____F ____ S ____ Su



Time

From _____ To _____




Environments

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



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


Yes
No

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


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


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


Yes
No

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




Activities

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



Is the array of activities in which the student participates during Time Segment # acceptable?
Yes
No
If "Yes," report why the array of activities in which the student participates during Time Segment # is acceptable.

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

Are there activities in which the student could or should participate during Time Segment # , but does not?
Yes
No
If "Yes," report the activities in which the student could or should participate during Time Segment # and why.


Time

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


Yes
No
If "Yes," report why the amounts of time the student participates in each activity during Time Segment # are acceptable.

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




Segment # 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 # acceptable?


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

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

Are there persons with whom the student should interact during Time Segment # , but does not?
Yes
No

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




Supervision

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


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 # acceptable?


Yes
No

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



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

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




Extra Support

Extra support refers to the PERSONNEL, INFORMATION-TRAINING, INDIVIDUALIZED ADAPTATIONS, MONEY, and OTHER phenomena a student and those who interact with her/him need in order to participate meaningfully in appropriate experiences after school and during weekends THAT WOULD NOT BE NEEDED IF HE/SHE WAS NOT DISABLED. In reality, it is often difficult or impossible to delineate mutually exclusive categories of support. However, attempts seem necessary here for organization and communication purposes.

Record the PERSONS who provide support during Time Segment # who would not do so if the student was not disabled.
Adult activity leader
Educational assistant
Special education teacher
Schoolmates without disabilities
Personal attendant
Volunteer
Respite worker
Parent/Guardian

Are the PERSONS who provide support during Time Segment # acceptable?


Yes
No

If "No," report why the PERSONS who provide support during Time Segment # are unacceptable.


Report the PERSONS who should provide support during Time Segment # , but do not, and the support they should provide.



In some instances those who interact with the student may be in need of INFORMATION and/or specific kinds of TRAINING that would not be needed if he/she was not disabled.

Record the extra INFORMATION-TRAINING that has been provided those who interact with the student during Time Segment # ?


Is the INFORMATION-TRAINING that has been provided those who interact with the student during Time Segment # is acceptable?


Yes
No

If "No," report why the INFORMATION-TRAINING that has been provided those who interact with the student during Time Segment # is unacceptable.



Is there additional INFORMATION-TRAINING that should be provided those who interact with the student during Time Segment # ?
Yes
No

If "Yes," report the additional INFORMATION-TRAINING that should be provided and who should receive it.



INDIVIDUALIZED ADAPTATIONS are the materials, assistive devices, sequences, regulations and other factors that have to be utilized, modified or created so that the student can function acceptably, that would not be needed if he/she were not disabled.
Record the INDIVIDUALIZED ADAPTATIONS used during Time Segment # .

Are the INDIVIDUALIZED ADAPTATIONS utilized during Time Segment # acceptable?
Yes
No

If "No," report why the INDIVIDUALIZED ADAPTATIONS utilized during Time Segment # are unacceptable.



Are there INDIVIDUALIZED ADAPTATIONS that might enhance the functioning of the student during Time Segment # ?
Yes
No

If "Yes," describe them and report how each might be used.


Record OTHER extra support provided during Time Segment # .



Is the OTHER extra support provided during Time Segment # acceptable.
Yes
No

If "No," report why the OTHER extra support provided during Time Segment # is unacceptable.


If there is extra support that should be provided during Time Segment # that has not been described above, report it below.



Record the amounts of MONEY being spent per typical day and week during Time Segment # , that would not be spent if the student was not disabled.
M $
T $
W $
TH $
F $
S $
S $
Total Per Week $

Is the amount of extra MONEY spent per typical week during Time Segment # acceptable?


Yes
No

If "No," report why the amount of extra MONEY spent per week during Time Segment # is unacceptable.


Parents cannot afford the extra costs.
The cost of paying professionals to assist the student could be reduced if proper adaptations were utilized.



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