The Next Move Program
Fostering Transition Internship Opportunities
Name: ____________________________
Functional Work Skills
Thank you for applying to be an intern with The Next Move Program. As a part of the application process and to
help us plan our internship positions, we ask that you fill out the form below. Answer honestly. There is no right or
wrong answer. Answer the questions to the best of your knowledge based on what you know about yourself. A
teacher or parent might be able to help you in completing this form. This information will assist us in matching our
internship applicants to jobs at the host business that best match their abilities.
Directions: For each functional skill listed below, place an [x] next to the appropriate answer.
Physical Skills
1. Finger dexterity work with small objects
can do
difficult
unable to do
2. Fingering pick up items with fingers
can do
difficult
unable to do
3. Handling hold, grasp and turn items
can do
difficult
unable to do
4. Manual dexterity move hands skillfully
can do
difficult
unable to do
5. Lifting 10 pounds or less
can do
difficult
unable to do
5b. Lifting 20 pounds or less
can do
difficult
unable to do
6. Motor coordination do tasks rapidly
can do
difficult
unable to do
The Next Move Program
Fostering Transition Internship Opportunities
7. Balance keep balance while standing, walking,
crouching, running
can do
difficult
unable to do
8. Speaking present words clearly and effectively
can do
difficult
unable to do
9. Crouching bend down by bending legs
can do
difficult
unable to do
10. Reaching extend arms in any direction
can do
difficult
unable to do
11. Carrying move things to another location
can do
difficult
unable to do
12. Set up get and arrange items needed
can do
difficult
unable to do
13. Stack put items in a neat pile
can do
difficult
unable to do
14. Stand for long periods of time
can do
difficult
unable to do
15. Sit for long periods of time
can do
difficult
unable to do
16. Endurance work for long periods of time
can do
difficult
unable to do
17. Pushing (light) push light items
can do
difficult
unable to do
can do
difficult
unable to do
Perceptual Skills
1. See (near) see items clearly at 20 inches or less
The Next Move Program
Fostering Transition Internship Opportunities
2. See (far) see items clearly at 20 feet or more
can do
difficult
unable to do
3. Color vision Identify and distinguish color and shades of
color
can do
difficult
unable to do
4. Clerical perception see detail and differences in printed
materials; accurately proofread words and numbers
can do
difficult
unable to do
5. Verbal perception perceive pertinent detail in verbal
communication
can do
difficult
unable to do
6. Hear perceive sounds clearly
can do
difficult
unable to do
1. Verbal aptitude (receptive) able to understand meanings
of words and ideas communicated verbally
can do
difficult
unable to do
2. Verbal aptitude (expressive) able to effectively express
thoughts and ideas verbally
can do
difficult
unable to do
3. Learning aptitude able to understand instructions, facts,
ideas, and concepts; able to reason and make judgments
can do
difficult
unable to do
4. Reading aptitude able to understand meaning of written
words and ideas
can do
difficult
unable to do
Aptitudes
The Next Move Program
Fostering Transition Internship Opportunities
5. Writing aptitude able to express thoughts and ideas in
writing
can do
difficult
unable to do
1. Classify things by group
can do
difficult
unable to do
2. Collate papers in order
can do
difficult
unable to do
3. Coordinate tasks and schedules
can do
difficult
unable to do
4. Copy papers and documents
can do
difficult
unable to do
5. File information and records
can do
difficult
unable to do
6. Organize work and tasks
can do
difficult
unable to do
7. Read for information
can do
difficult
unable to do
8. Record numbers or words
can do
difficult
unable to do
9. Sort items into groups
can do
difficult
unable to do
10. Write messages
can do
difficult
unable to do
Work Task Skills
A. Data
The Next Move Program
Fostering Transition Internship Opportunities
11. Use and operate a computer
can do
difficult
unable to do
12. Enter and store information on a computer
can do
difficult
unable to do
13. Find information stored on a computer
can do
difficult
unable to do
14. Use e-mail
can do
difficult
unable to do
1. Follow instructions
can do
difficult
unable to do
2. Accept supervision
can do
difficult
unable to do
If you answered “difficult” or “unable to do” in question 11,
check the reasons why below:
___too hard to learn
___not been trained
___do not have computer access
___cannot read screen
___cannot operate keyboard
___cannot operate the mouse
Performance
The Next Move Program
Fostering Transition Internship Opportunities
3. Complete tasks
can do
difficult
unable to do
4. Meet deadlines
can do
difficult
unable to do
5. Maintain good attendance
can do
difficult
unable to do
6. Persevere (face challenges but continue working)
can do
difficult
unable to do
7. Work independently
can do
difficult
unable to do
8. Learn new skills
can do
difficult
unable to do
9. Stay motivated
can do
difficult
unable to do
10. Be on time
can do
difficult
unable to do
11. Follow procedures
can do
difficult
unable to do
12. Be responsible
can do
difficult
unable to do
13. Work well with others
can do
difficult
unable to do
14. Be trustworthy
can do
difficult
unable to do
15. Get along with others
can do
difficult
unable to do
16. Manage anger
can do
difficult
unable to do
17. Manage stress
can do
difficult
unable to do
The Next Move Program
Fostering Transition Internship Opportunities
18. Stay on task
can do
difficult
unable to do
19. Be agreeable
can do
difficult
unable to do
20. Be self-directed
can do
difficult
unable to do
21. Act maturely
can do
difficult
unable to do
22. Wear a smile!
can do
difficult
unable to do
Adapted from: (Jacobs, Robin. "Career and Employment Guide for Job Seekers and Employees with Disabilities and Guide for Employers: How to Recruit, Interview hire and
AccommodatePeoplewithDisabilities."Pcc.edu.Pcc.edu,03Sept.2003.Web.27Feb.2013.<http://spot.pcc.edu/~rjacobs/career/index.htm>.)