Fill out a health history form
When to use this goal
For high school and transition students who will soon fill out their own forms at clinics, job sites, and colleges, but cannot yet complete name, birth date, allergies, medications, and emergency contact fields correctly. Present levels decide fit.
- Baseline
- Score the fields on one practice form (usually 15 to 25) against the information the family confirms. Note which fields are blank versus wrong.
- Tips
- Build a personal health information card with the family first. Practice forms use made-up identifiers when shared with peers. Teach the student to leave a field blank and ask rather than guess.
- Limits
- Accuracy depends on the family confirming the facts. Forms with medical history sections may need a family member's help; that is a fair support. This goal never replaces the individualized health plan, medication orders, or an emergency action plan; the nurse, the family, and the student's health care provider decide care, and the goal follows their plan.
Original IEP Atlas template based on general measurement principles; not copied from any goal bank. ID fn-hlt-023.
Sign in to add this goal to a student.
Goal
By the annual IEP review date, given a practice health history form like those used at local clinics, the student will complete each field of the form with accurate information about themselves independently with at least 90% accuracy on form fields, in 3 of 4 consecutive monthly probes, as measured by work-sample analysis collected monthly.
Baseline: 40% accuracy.
- Condition
- Observable behavior
- Criterion
- Measurement method
Measurability check11 of 11 met
Met: Observable behavior. Stated as an action.
Met: Condition. Stated.
Met: Unit fits the behavior. Percent accuracy fits this behavior.
Met: Explicit criterion. Number and unit stated.
Met: Mastery rule and schedule. Both stated.
Met: Method produces the metric. Work-sample analysis gives percent accuracy data.
Met: Review timeframe. Stated.
Met: Baseline and target compatible. Same unit, change in the right direction.
Met: Aligned with area of need. Still about Health & Self-Management.
Met: Level of support. Defined.
Met: Blanks filled in. Nothing left to fill in.
Checks structure and wording only. Whether the goal fits the student is the team's call.
Short-term objectives (optional)
When are objectives required?Required for students on alternate assessments (34 CFR §300.320(a)(2)(ii)); some states require them for everyone.
Paste into your IEP system
Most district systems have a separate box for each part of a goal. Copy them one at a time, or all at once as labeled text.
- Area of need
- Functional & Independence Skills - Health & Self-Management
- Baseline
- 40% accuracy.
- Annual goal343 characters
- By the annual IEP review date, given a practice health history form like those used at local clinics, the student will complete each field of the form with accurate information about themselves independently with at least 90% accuracy on form fields, in 3 of 4 consecutive monthly probes, as measured by work-sample analysis collected monthly.
- Timeframe
- By the annual IEP review date
- Condition
- Given a practice health history form like those used at local clinics
- Behavior
- The student will complete each field of the form with accurate information about themselves independently
- Criteria
- With at least 90% accuracy on form fields, in 3 of 4 consecutive monthly probes
- Evaluation method
- Work-sample analysis
- Schedule
- Monthly
Copied as plain text, with straight quotes and plain dashes.
Matching data sheet
Accuracy tracker. Records number correct and number attempted.
Accuracy tracker
Percent accuracy- Student label:
- Target:
- with at least 90% accuracy on form fields
- Mastery rule:
- in 3 of 4 consecutive monthly probes
- Collection schedule:
- monthly
- Method:
- Work-sample analysis
- Data collector:
Goal: By the annual IEP review date, given a practice health history form like those used at local clinics, the student will complete each field of the form with accurate information about themselves independently with at least 90% accuracy on form fields, in 3 of 4 consecutive monthly probes, as measured by work-sample analysis collected monthly.
| Date | Task / materials | # correct | # attempted | % accuracycorrect ÷ attempted × 100 | Support levele.g., independent, 1 verbal prompt | Notes |
|---|---|---|---|---|---|---|
Preview shows 4 of 12 rows.
- Score only items the student attempted unless the goal defines a fixed set of items. Use the same denominator every session.
- Percent = numerator ÷ denominator × 100. Round to one decimal place.
- Record the support actually provided, even if the goal is independent performance.
The CSV opens in Excel or Google Sheets, with formulas. Sheets print blank; no student data is stored.