Project SEARCH Medical Center - Clinton ...
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Project SEARCH AZ
Application 2009/2010
2022-23 Application Packet
Project
SEARCH
MercyOne
Medical
Center
Applications are Due to Carol Aden by January 14, 2022
Questions/Tours scheduled w/ Mrs. Kokjohn, 563.219.1966
Name
High School
Project SEARCH MercyOne Medical Center
Application 2022-2023 High School Transition Program — Entrance
Criteria
Be at least 18 years of age.
Completed high school credits necessary for graduation.
Students will accept diploma upon exiting Project SEARCH.
Meet eligibility requirements for Iowa Vocational Rehabilitation Services
(IVRS).
Meet eligibility requirements for long-term supports for follow along services.
Have independent personal hygiene and grooming skills.
Have independent daily living skills.
Maintain appropriate behavior and social skills in the workplace.
Take direction from supervisors and modify performance.
Be able to communicate effectively with or without accommodation.
Utilize independent transportation or participate in travel training to insure
success in using the bus independently.
Have previous experience with limited supports in a work environment
(including school, volunteer, and paid work).
Ability to pass drug screen, background check
Immunizations are up to date, including, Covid-19 Vaccine
Flu shot will be required prior to flu season.
Willingness to produce guardianship papers, diagnosis, and medication list.
Desire and plan to work competitively in the community upon exiting
Project SEARCH.
It is the policy of the Clinton Community School District not to discriminate on the
basis of race, color, national origin, sex, disability, religion, creed, age (for
employment), marital status (for programs), sexual orientation, gender identity, and
social economic status (for programs) in its educational programs and its
employment practices. There is a grievance procedure for processing complaints of
discrimination. If you have questions or a grievance related to this policy, please
contact the district’s Equity Coordinators:
Wes Golden Rhea Wright
Equity Co-Chair Equity Co-Chair
1401 12th Avenue North 1401 12th Avenue North
Clinton, IA Clinton, IA
563.243.9600 x 50 563.243.9600 x 26
wgolden@clintonia.org rheawright@clintonia.org
1Project SEARCH MercyOne Medical Center
Application 2022-2023
Application Purpose & Guidelines
The purpose of this application packet is to outline the skill set of the Project
SEARCH student candidate. This application then enables the Selection Committee*
to properly assess each student candidate’s skills, abilities and background. A
parent, student, counselor, teacher or employer may be contacted by the Selection
Committee to gather additional information. Our final goal is to select students who
will be successful in a Project SEARCH program and reach the outcome of
competitive employment.
The Selection Process includes the following guidelines:
1. Recruitment is held in the spring of each year. To ensure proper assessment,
all students must complete this packet of information completely, to be
considered for participation in the Project SEARCH program. See checklist
on the following page.
2. Perspective interns will participate in a Skills Assessment Day. Part of this
day will include a 20-minute interview with members of the Selection
Committee
3. Because the individual with a disability is at the center of every activity
presented in Project SEARCH, families play a key role in being involved.
Parents must be willing to attend and contribute to six Employment Planning
Meetings and four family meetings (Orientation, Fall Family Meeting, Spring
Family Meeting, and Graduation.)
*Please note Selection Committee members include:
Director of Student Services, Clinton Community School District (CCSD)
Instructor, Clinton Community School District (CCSD)
Transition Specialist, Mississippi Bend Area Education Agency (MBAEA)
Family & Educator Coordinator, Mississippi Bend Area Education Agency
(MBAEA)
Business Liaison, MercyOne Medical Center-Clinton
Counselor, Iowa Vocational Rehabilitation Services (IVRS)
Director of Employment Services, Skyline Center, Inc.
Job Developer and/or Skills Trainer, Skyline Center, Inc.
By filling out an application does not guarantee an internship.
2Project SEARCH MercyOne Medical Center
Application 2022-2023
Application Packet Checklist
2021- Sept 1 Project SEARCH
Application Packets
available
2022- January 14 Application Packets Due
February 1 Letters sent to Parents to
schedule interviews
February 23 Student Interviews/Skills
Assessment Day, Selection
Committee Discussion
March 1 Notification Letters
(acceptance and
declination) sent to
applicants by MercyOne
May 16-23 IEPs reviewed in May
with affiliated school and
team members
August TBD New Student Orientation
August TBD First Day of School
3Project SEARCH MercyOne Medical Center
Application 2022-2023
Please note: All required documents must be completed and submitted
together for consideration.
Completed Application
Completed Teacher Assessment Rubric (attached)
Immunization Record
Two (2) Letters of Recommendation (non-family member)
Current Individual Education Plan (IEP) including Transition Goals
Iowa Vocational Rehabilitation Services letter for eligibility
Transcripts
We will need copies of State ID and Social Security Card if selected for an
internship at the onset of the program. Proof of Guardianship, Diagnosis and
Medication List will also be necessary, as well as release of information.
Return completed Application Packet to: Carol Aden/Family & Educator Coord.
Mississippi Bend Area Education Agency
2001 Manufacturing Ct.
Clinton, IA 52732
caden@aea9.k12.ia.us
563.344.6287
Questions/Tour can be scheduled with: Mary Beth Kokjohn/PS Instructor
Clinton Commnity School District
mbkokjohn@clintonia.org
563.219.1966Project SEARCH MercyOne Medical Center
Application 2021-2022
Application for Admission (1 of 5)
The following information is to be completed by the student, parents/guardians,
and teachers collaboratively:
A. Personal Data
Name:
Last First Middle
Address:
Student
Street City Zip Code
School Currently
Attending:
Home Cell
Phone: Phone: e-mail:
Choose One:
Date of Birth: (optional) Male Female
Parent/Guardian
Name: e-mail:
Address:
Street City Zip Code
Home Cell Work
Phone: Phone: Phone:
B. Parent/Student Information:
Parent/Guardian
Signature: Date:
Student
Signature Date:
Check if parent is legal guardian.
5Project SEARCH MercyOne Medical Center
Application 2022-2023
Application for Admission (2 of 5)
C. School Personnel Use Only: Please attach transcript and most recent report card
Total Credits to
Date: Cumulative GPA
Does the student have the necessary credits for
graduation? Note: Student must have made
arrangements to defer the High School Diploma. Yes No
1. 2.
List Clubs &
Activities:
(if any) 3. 4.
11th 12th
Days Absent: Grade Grade
Comments about Academic Performance and/or Attendance:
TRANSPORTATION – Interns will NOT have transportation provided by the Clinton Community
School District. Part of work learning is figuring out how to transport self to work. Bus Training or
Setting up a bus arrangement can cooperatively occur in early August by the instructor, support
staff, and parent/s.
How do you plan to get to Project SEARCH?
MTA Parents Paratransit/Riverbend
Walk Drive Self
LUNCH – Interns will NOT be involved in the CCSD school lunch program, including the Free &
Reduced Lunch Program. Part of work learning is figuring out how to pack a lunch or use money in
the hospital cafeteria.
What will your lunch plans be?
Pack Café Both
6Project SEARCH MercyOne Medical Center
Application 2022-2023
Application for Admission (3 of 5)
D. Future Employment & Background:
1. How do you want to be employed in the community upon completion of Project SEARCH?
Full time Part time
2. Which shift would you prefer working after graduating from Project SEARCH?
1st Shift 2nd Shift 3rd Shift
3. Would you be willing to work holidays and/or weekends?
Yes No
4. Do you plan to work during the school year, in addition to being in the Project SEARCH
Program?
Yes No
If yes where? How many days/ hours?
5. List jobs you do or have done in school or in the community:
Employer/Job Title Job Duties Supervisor Name / Contact Paid /
Number Unpaid
1. Supervisor
Employer: Name:
2.
3.
Contact Paid
Job Title: 4. Number: Unpaid
1. Supervisor
Employer: Name:
2.
3.
Contact Paid
Job Title: 4. Number: Unpaid
1. Supervisor
Employer: Name:
2.
3.
Contact Paid
Job Title: 4. Number: Unpaid
1. Supervisor
Employer: Name:
2.
3.
Contact Paid
Job Title: 4. Number: Unpaid
7Project SEARCH MercyOne Medical Center
Application 2022-2023
Application for Admission (4 of 5)
6. Have you ever been fired from a job?
Yes No
If yes, please explain:
7. Have you ever quit a job?
Yes No
If yes, please explain:
E. Service Agencies:
1. Do you have a Vocational Rehabilitation Counselor (IVRS)?
Yes Name: Phone Number:
No
2. Are you eligible for long-term supports for follow along services?
Yes Name: Phone Number:
No
F. Student Response Questions:
1. Why do you want to come to Project SEARCH? (Complete in your own words and/or
person assisting will write the responses in the students own words)
8Project SEARCH MercyOne Medical Center
Application 2022-2023
Application for Admission (5 of 5)
2. Please see the Project SEARCH schedule below. Are you able to participate in this schedule
on a daily basis?
Yes
No If no, please explain:
8:00am 9:00am Classroom instruction at the business site
Project SEARCH
Daily Schedule
9:00am 11:30am Worksite rotation
11:30am12:00pm Lunch
12:00pm 2:00pm Worksite rotation
2:00pm 2:30pm Reflection with instructor and supervisor
G. References – List who we can expect to get references from – only need 2 of the 3.
Name Type of Reference Phone Number Email Address
1. Family Reference
2. School Reference
Other Community or
3. Agency Reference
H. The person assisting the student to complete this application is:
Name Title Date
Organization Phone Number Email contact
Signature
9Project SEARCH MercyOne Medical Center
Application 2022-2023
Application for Admission (5 of 5)
Dear Project SEARCH Applicant:
On the following pages, you will find a Project SEARCH rubric that needs to
be filled out and signed by the teacher. Please inform the teacher to read
through each point carefully, and circle the description that would best fit
current information about yourself and your skills. This will help the Project
SEARCH team learn more about you and determine the best program to
assist with your transitional needs. If you have any questions and/or
concerns, please contact Kathy Anson/Family & Educator Coordinator at
563.242.6454 or Mary Beth Kokjohn/Project SEARCH Coordinator at
563.219.1966
Thank you!
The Project SEARCH Staff
10Project SEARCH MercyOne Medical Center
Application 2022-2023
Project SEARCH Student Selection Rubric Guide
Teacher Assessment
Student name______________________________ Teacher Signature__________________________
TOTAL SCORE: (out of a possible 90):___________ DATE_____________________
Criteria 1 2 3 4 5
Age and School Status Under 18 or over 22 years Student has had two or Student needs one or two Student has had two possible Student will be in last year of
of age more possible years of credit requirements for years of school eligibility school eligibility and has all
school eligibility, lacks graduation and can be fulfilled remaining but student agreed credits necessary for high school
maturity and is working through participation in the PS that this will be the last year and graduation or will be able to
toward skills for HS program has the end goal of employment receive certificate of completion
employment
Commitment to Student is unsure of Student is unsure of interest Student demonstrates One member of the team, Student and family are
Community Employment interest in community in community employment commitment to work but has student or family member may committed, appropriate and will
employment but parent is supportive and significant restrictions such as be non-committal to the goal of be flexible to meet the work goal
encouraging inappropriate work goal, community employment
location, type of work, etc.
Attendance 10+ unexcused absences 10+ excused and unexcused 5-10 excused and unexcused 1-5 excused absences or tardies No absences or tardies within
absences or tardies within absences or tardies within the within the past school year the past school year
the past school year past school year
Independent Daily Living Student has very poor or Student has not been Student has participated in Through training, the student Student practices and
and Self Care Skills no independent daily exposed to any daily living limited or informal training for demonstrates basic proficiency demonstrates daily living and
living and self-care skills. skills training but displays daily living and self-care skills. in daily living skills and self-care self-care skills such as cooking,
They may rely on parents some skills in these areas S/he can demonstrate minimal skills. Self-care skills include sleeping, budgeting, handling
and staff for some basic and in self-care. Team skills in these areas. If toileting, feeding, taking money, and is also able to take
needs to be met should begin planning for toileting and feeding are still medication, bathing, etc. care of self-care needs
training/practice in these dependent, team could independently
areas investigate accommodations
Appearance and Student does not possess Student needs assistance in Student wears neat and clean Student is neat, clean and well- Student has good personal
Professional any personal hygiene making sure clean clothes clothing and has appropriate groomed but makes hygiene skills and will arrive to
Presentation skills and clothes are not are worn daily. Personal grooming on most days inappropriate clothing choices Project SEARCH and/or work
neat and clean appearance may vary each for work based on place of clean and according to the dress
day business, dress code and code and weather
weather.
Student is not eligible, Family is willing to provide Student is eligible for Student can utilize public Student can utilize public
Transportation has not been trained in on-going transportation to transportation from outside transportation including a door- transportation and/or door-to-
any independent method the Project SEARCH and/or resources like MRDD or other to-door system with basic skills door system as well as other
and family cannot provide community work site disability related service transportation options (cab)
Appropriate Social and Student frequently Student periodically displays Student is appropriate in the Student display appropriate Student displays appropriate
Behavior Skills displays inappropriate inappropriate social and presence of adult supervision social and behavior skills in most social and behavior skills in all (or
social and behavior skills behavior skills but is not independent situations nearly all) situationsProject SEARCH MercyOne Medical Center
Application 2022-2023
Interpersonal Student has no grasp of Student uses appropriate Student engages is some Student engages in conversation Student uses appropriate tone of
Communication interpersonal body language (smiles, conversation when prompted independently but the topic is voice, body language and
relationships waves, etc.) but does not inappropriate conversation topics
engage in appropriate
conversation
Verbal Communication Student has no way of Student is not fluent or Student can be understood Student uses a voice box or Student has the ability to
clearly communicating easily understood even with with 1-2 repetitions or when other assistive technology to communicate with all others and
with others assistive technology or asked to speak more clearly communicate and is understood be understood easily
support using these tools
Problem Solving and Student has no Student has difficulty in Student has demonstrated Student possesses good problem Student possesses good problem
Conflict resolution independent problem problem solving and conflict capacity to expand problem solving skills solving skills and initiates
solving and conflict resolution skills solving and conflict resolution problem solving independently
resolution skills skills
Physical Ability Student has limited Student has the mobility Student has low but improving Student has the mobility and Student has the ability, mobility
■ Mobility physical abilities as well and stamina to perform mobility and stamina and stamina to perform all tasks with and stamina to perform all tasks
■ Stamina as limited capacity to take some of the tasks including ability to take care of own accommodations. The student including self-care independently
care of own personal personal needs with personal self-care needs has developed strategies to take and successfully
needs limitations care of own personal needs with
limited assistance
Student is methodical which Student can achieve Pace and quality of work are Student is able to achieve both
Pace and Work Quality Student seldom gets work affects pace, productivity appropriate work pace but mildly deficient but improving quality and quantity of work,
finished in allotted time and output quality suffers or work quality and work is neat maintains neatness/organization
period or by deadline is sufficient but quantity is and completes work according to
affected deadlines
Employability Skills Student has not been Student has participated in Student has had one year or a Student has had more than one Student demonstrates
exposed to any limited or informal consistent class devoted to year of employability skills independent living skills and has
employability training employability training employability skills training 2 or more years of employability
training
Prior Work Experience Student has no prior work Student has had one or Student has volunteer or paid Student has had one or less Student has had more than one
experience more in-school work enclave work experience years of competitive work year or multiple competitive
experience experience work experiences
Independence Student requires ongoing Student requires frequent Student requires job coaching Student is able to work without Student requires coaching at
job coaching support job coaching support while 50 – 75 % of the time. coaching most of the time. beginning and for problem
while on a job site. on a job site. solving.
Academic Skills Student cannot read nor Student has some basic Student can read simple Student can read and All academic skills are above a 4th
do any simple math academic skills such as rote functional information and can comprehend material at or grade level
computations counting and can file using perform simple math above a 2nd grade level, can tell
two to three digits with computations (with or without time with a clock or analog
numbers or letters a calculator) watch to five minutes and count
money/make change
Computer Skills Student has no computer Student has basic Student can access internet, Student can utilize some Student can utilize Microsoft
skills knowledge of keyboard and utilize search engines for Microsoft products at a beginner products, save, edit & retrieve
keyboard functions information & entertainment level documents with basic proficiencyYou can also read
