Kitchen Task Assessment Form
Client Name
First Name
Last Name
Examiner
First Name
Last Name
Date
 -
Month
 -
Day
Year
Date
Level of Support
Independent=0, Required verbal assistance=1, Required physical assistance=2, Not capable=3
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Please select the level of support that the individual required.
Initiation
Was he or she able to start when told to do so?
Independent
Required verbal assistance
Required physical assistance
Not capable
Organization
Was he or she able to gather the necessary items, tools, ingredients, etc.?
Independent
Required verbal assistance
Required physical assistance
Not capable
Performs All Steps
Was he or she able to do all the necessary steps in order to complete the task?
Independent
Required verbal assistance
Required physical assistance
Not capable
Sequencing
Was he or she able to do all the necessary steps in the correct order?
Independent
Required verbal assistance
Required physical assistance
Not capable
Judgement and Safety
Was he or she safe and aware of potential dangers?
Independent
Required verbal assistance
Required physical assistance
Not capable
Completion
Was he or she able to understand that the task was completed?
Independent
Required verbal assistance
Required physical assistance
Not capable
Total Score
Submit
Should be Empty: