Rate Client

Here
Concentrating on my tasks
Physically doing what I need to do
Taking care of the place where I live
Taking care of myself
Taking care of others for whom I am
responsible
Getting where I need to go
Managing my finances
Managing my basic needs
Expressing myself to others
Getting along with others
Identifying and solving problems
Relaxing and enjoying myself
Getting done what I need to do
OSA Competence Key
1 1
1 1
1 1
1 1
1 1
1 1
1 1
1 1
1 1
1 1
1 1
1 1
2 3
2 3
2 3
2 3
2 3
2 3
2 3
2 3
2 3
2 3
2 3
2 3
4 4
4 4
4 4
4 4
4 4
4 4
4 4
4 4
4 4
4 4
4 4
4 4

Having a satisfying routine

1
1
1
1
2
2
3
E
3
4
4
4
4
Handling my responsibilities 1 1 2 3 4 4
Being involved as a student, worker,
volunteer, and/or family member
1 1 2 3
L 4 4
Doing activities I like 1 1 2 3 4 4
Working towards my goals
Making decisions based on what I think is
1
1 1
P 1

2
2

3
3

4
4 4
4
important
Measure client here. Circle ratings and draw line.

Accomplishing what I set out to do 1 1 2 3 4 4

Effectively using my abilities

Total Score _________

1
M 1 2 3 4 4

-2
-4
-6
-8

–0
- 12
- 14
- 16
- 18
- 22
- 24
- 26
- 28
- 32
- 34
- 36
- 38
- 42
- 44
- 46
- 48
- 52
- 54
- 56
- 58
- 62
- 64
- 66
- 68
- 72
- 74
- 76
- 78
- 82
- 84
- 86
- 88
- 92
- 94
- 96
- 98

– 10
– 20
– 30
– 40
– 50
– 60
– 70
– 80
– 90

Me
– 100

asu
re
A 8
5
5
4
4
3
3
3
3
3
3
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
3
3
3
3
4
4
4
5
5
8

14
14

Err
or

21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84

Tot
al S
cor
S
Client Measure ______
0
9
14
18
20
22
24
25
27
28
29
30
31
32
33
34
35
36

e
36
37
38
39
40
41
41
42
43
44
45
45
46
47
48
49
50
51
52
53
53
54
55
57
58
59
60
61
62
63
64
65
66
68
69
70
71
73
74
76
77
80
82
85
91
100

Me
asu
re
8
5
5
4
4
3
3
3
3
3
3
3
3
3
3
3
3
2
2
2
2
2
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
4
4
4
5
5
8

14
14

R 12-04 Standard Error ______ Err

or