`SAMPLE CHART

Work Behaviours
Rating Scale:
1 Completely unacceptable for employment
2 Mostly unacceptable for competitive employment
3 Barely acceptable for competitive employment
4 Mostly acceptable for competitive employment
5 Completely acceptable for competitive employment
N Not applicable or observed
Work Behaviour

Following
Directions
Communication
2-step
instructions
Attention Span

Comments

Difficulty noted for Payroll Computation and

Patient Information Memo
No difficulty noted
No difficulty noted

Decision
Making
Ability to
Tolerate
Pressure
Interaction with

Difficulty focusing on work due to pain towards the

end of the day
Able to make independent decisions when presented
with assembly tasks (use of tools and methods in
situational tasks)
Aware of time restraints

Co-Workers
Interaction with
Supervisor
Breaks

Cooperation
Initiative

Requires work breaks due to pain and fatigue (micro

breaks every 15 minutes for 5 minutes, especially in the
afternoon hours ).
Co-operates with completion of most tasks
Often takes initiative but becomes less capable as time
progresses
Begins tasks independently and tries to complete work
started despite difficulties, corrects own mistakes
Difficulty sustaining performance and to stay on tasks
requiring either prolonged sitting or standing.
Accepts delegated chores and does not express
dissatisfaction. Work performance and attitude is
consistent; output drops because of need to alleviate
back pain.
Difficulty noted when performing tasks requiring
writing and following written instructions.

Motivation
Flexibility

Seems comfortable relating to supervisor/assessor

Reaction to
Repetitious
Work

Ability to Work
Independently
Ability to
Accept
Criticism
Hygiene
Appearance