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John has the disability label of "Mental Impairment" and is considered "non-verbal." John's PASS will be used for employment identification through four on the job experiences and will pay for OJT employer costs, transportation, and job coaching support. The yearly cost is $706.67. This PASS is for 3 years and a total amount of $2,120.00. This PASS comes from the Denver Regional SSA Office.


A. What is the nature of your disability?
My primary disability is mental retardation.
B. Explain any limitations you have because of your disability (e.g., limited amount of standing or lifting, etc.)
Cognition and language impairments will affect how I participate and communicate on the job. Currently I require assistance in transportation, and significant on-the-job training supports such as those provided through supported employment strategies.
C. List the types of jobs you have had most often in the past few years and those you have had which are similar to your work goal. Also show how long you worked (i.e., how many months or years) in each type of job.
Although I have not yet had the opportunity to perform formal work, I do the following informal chores at home and at school. I assist with copying and general office tasks in the school office and run errands for the office and for teachers. At home I have extensive un-paid experience with ranch chores and small farm animals, including mucking stalls, assisting with mending fences, and livestock feeding chores.
D. Check the block which describes the highest educational level you have completed: [X] Elementary school [] High school graduate or G.E.D. [] Some college [] College graduate [] Post graduate courses [] Postgraduate degree [] Trade or Vocational School [] Other (Specify): If you completed college, list your major and degree(s) attained; if you completed one or more courses in a trade or vocational school, list the trade(s) you learned: N/A
E. Describe any other training you have received:
The skills which I have acquired through my informal jobs at school and home which will be useful in a paid job situation are: following directions, learning routines of jobs and locations of equipment and supplies, and interacting with various people throughout my home ranch environment and the school.
F. Have you ever undergone a vocational evaluation? [] Yes [X] No If yes, show the name, address and phone number of the person or organization who conducted the evaluation: G. Have you ever had a Plan for Achieving Self-Support before? [] Yes [X] No If yes, please answer the following: When was your prior plan approved (month/year)? N/A When did it end (month/year)? N/A What was your goal in the prior plan? N/A Why did your prior plan not enable you to become self-supporting? N/A Why do you believe that this plan will be successful?
I have a strong support group comprised of family, friends, school staff, and a local Community Based Rehabilitation Organization.
H. If someone is helping you prepare this plan, please give their name, address and telephone number:
KLM, Special Educator, Anytown Schools, Anytown, Anystate 00000, (XXX) 111-0000. J&S Anyone (my parents) (XXX) 111-0000. WJD, Community Based Rehab Organization, (XXX) 111-0000
Do you want us to contact the person who is helping you if we need additional information about your plan? [X] Yes [] No Do you want us to send a copy of our decision on your plan to the person who is helping you? [X] Yes [] No