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CHECKLIST FOR PROGRAM PARTICIPANTS WITH PHYSICAL DISABILITIES

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Student Name: ___________________________________________________


Home City: ________________________ Country: ________________________


Congratulations on being accepted to the Kennedy-Lugar YES program! To help us serve your needs as a program
participant, and so that we can work together for a successful exchange experience, please answer the following
questions in as much detail as possible. This form will be used for reference when arranging your travel, and locating a
host family and U.S. high school that will be able to accommodate your needs. Your local YES staff will assist you in
filling out this form.

In your own words, please describe your disability:









EQUIPMENT

1. What equipment do you currently use? Circle all that apply.
(Note: Always = every day; Sometimes = at least once per week)

1. Crutches Always Sometimes Never 7. Sliding board Always Sometimes Never
2. Braces Always Sometimes Never 8. Shower chair Always Sometimes Never
3. Cane(s) Always Sometimes Never 9. Grab bars
(handles on wall)
Always Sometimes Never
4. Walker Always Sometimes Never 10. Hand-held
shower hose
Always Sometimes Never
5. Manual wheelchair Always Sometimes Never 11.Prosthetic
device
Always Sometimes Never
6. Power wheelchair Always Sometimes Never 12. None
Other (describe):




2. What equipment that you will bring to the US? Circle all that apply.

Crutches Manual wheelchair Extra wheelchair parts
Braces Power wheelchair Tires
Cane(s) Sliding board Tubes
Walker Battery charger Transistors
Wheelchair batteries (acid type) Other parts None
Wheelchair batteries (gel type) Other (describe)




Disabilities



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HOME LIFE

1. Who, if anyone, assists you with your personal care? Please list all:





2. Circle the level of assistance you need for the following activities and describe the type of
assistance:

Bathing and grooming No Assistance Sometimes Use Assistance Always Use Assistance
Please describe the techniques, assistance or equipment you use to do this at home:


Showering No Assistance Sometimes Use Assistance Always Use Assistance
Please describe the techniques, assistance or equipment you use to do this at home:


Getting dressed No Assistance Sometimes Use Assistance Always Use Assistance
Please describe the techniques, assistance or equipment you use to do this at home:


Using the toilet No Assistance Sometimes Use Assistance Always Use Assistance
Please describe the techniques, assistance or equipment you use to do this at home:


Taking medication No Assistance Sometimes Use Assistance Always Use Assistance
Please describe the techniques, assistance or equipment you use to do this at home:


Preparing meals by yourself No Assistance Sometimes Use Assistance Always Use Assistance
Please describe the techniques, assistance or equipment you use to do this at home:


Doing house work No Assistance Sometimes Use Assistance Always Use Assistance
Please describe the techniques, assistance or equipment you use to do this at home:


Disabilities



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SCHOOL

1. Tell us about who attends your school:

Only students with physical disabilities Only students who have disabilities (physical and
other disabilities)
I am the only student who has a disability Students with and without disabilities


2. Please describe in detail the techniques, equipment, adaptations or assistance you use to study (read
textbooks, write, take notes, participate in class, do homework, and so forth):








3. Writing and Computer Usage:

Can you write with a pen or pencil? Easy Need Assistance No
How do you write in your local language? Fast Slow
How do you write in English? Fast Slow
Do you need extra time or breaks when writing? If yes,
describe:



Yes No
Do you use a computer? Every day Sometimes Never
Do you use the Internet (email, web)? Every day Sometimes Never
How do you type in your local language? Fast Slow Not at all
How do you type in English? Fast Slow Not at all

Please describe in detail any the techniques, adaptations, assistance or equipment you use (name of computer
equipment, adaptive equipment or software programs, how it works and so forth.):












Disabilities



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COMMUNITY

1. Please list your activities outside of school:






2. Tell us about who takes part in these activities (check all that apply):

Only students with physical disabilities Only students who have disabilities (physical and
other disabilities)
I am the only student who has a disability Students with and without disabilities


GETTING AROUND

1. Circle the answers that apply to you:
Can you carry a 5Kg backpack? Easy Need Assistance No
Can you carry a 30Kg suitcase? Easy Need Assistance No
If you use a wheelchair:
Can you roll your wheelchair without
assistance?

Yes No
How far can you roll your wheelchair without
assistance?

100 meters 200 meters kilometer 1 kilometer
Do you push your wheelchair by yourself? If not,
who usually pushes you?

Always Sometimes Never


2. Transportation (circle the answers that apply to you):

Can you:
Get into a car? Easy Need Assistance Not Possible
Get into a van? Easy Need Assistance Not Possible
Get on a bus? Easy Need Assistance Not Possible
Get on a train? Easy Need Assistance Not Possible

Please describe specifically the techniques, assistance or equipment you use to complete these
activities:






Disabilities



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3. Walking (circle the answers that apply to you):

Can you walk without assistance,
equipment or support (such as a railing)?
Please explain.


Yes No

Can you:


Walk on flat city streets?
1 block Easy Need Assistance Not Possible
5 blocks Easy Need Assistance Not Possible
20 blocks Easy Need Assistance Not Possible








Walk on uphill paved city streets?
1 block Easy Need Assistance Not Possible
5 blocks Easy Need Assistance Not Possible
20 blocks Easy Need Assistance Not Possible
Walk on uneven, unpaved surfaces (grass,
gravel, etc.)?

25 meters Easy Need Assistance Not Possible
200 meters Easy Need Assistance Not Possible
1 kilometer Easy Need Assistance Not Possible

Please describe specifically the techniques, assistance or equipment you use to complete these
activities.







4. Sitting (circle the answers that apply to you):
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Can you stand without assistance? Yes No
Can you stand for:
5 minutes? Easy Need Assistance Not Possible
20 minutes? Easy Need Assistance Not Possible
45 minutes? Easy Need Assistance Not Possible
Longer (specify)?
Can you sit for:
5 minutes? Easy Need Assistance Not Possible
30 minutes? Easy Need Assistance Not Possible
60 minutes? Easy Need Assistance Not Possible
4 hours? Easy Need Assistance Not Possible
Longer (specify)?

5. Stairs (circle the answers that apply to you):

Stepping up and down stairs
with a railing/wall:

1 step Easy Need Assistance Not Possible
5 steps Easy Need Assistance Not Possible
20 steps Easy Need Assistance Not Possible
Stepping up and down stairs
without a railing/wall:

1 step Easy Need Assistance Not Possible
5 steps Easy Need Assistance Not Possible
20 steps Easy Need Assistance Not Possible

Please describe specifically the techniques, assistance or equipment you use to complete these
activities.









Disabilities



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NEW EXPERIENCES

What new experiences would you like to try during your YES year?

Adaptive technology (technology to make an
activity accessible to people with disabilities):
Yes No Maybe
Describe:


New sport, recreation activity: Yes No Maybe
Describe:


Other new activity or experience: Yes No Maybe
Describe:



Please tell us anything else that we need to know about how you do things or your interests: