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OPHI II Data Summary Sheet

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					                                             OPHI-II Data Summary Sheet

     Date:
       Therapist_______________________                   Occupational Identity Scale                          1   2       3      4
       Student:________________________
                                                          Has personal goals and projects
     Informed Consent Status:
          Informed consent obtained and attached          Identifies a desired occupational lifestyle
          Informed consent obtained and on client
          record                                          Expects success
          Interview collected as part of clinical data
                                                          Accepts responsibility
          and submitted for secondary analysis
     Non-English Translation used? No Yes                 Appraises abilities and limitations
     If yes, specify which language:
          Chinese                  German
                                                          Has commitments and values
          Danish                   Icelandic              Recognizes identity and obligations
          Dutch                    Japanese
          Finnish                  Portuguese             Has interests
          Flemish-Dutch            Spanish
          French                   Swedish                Felt effective (past)
     Country Where Data Collected:                        Found meaning and satisfaction in lifestyle (past)
     _________________________________
                     Client Information                   Made occupational choices (past)
     Name: (initials only)                                Occupational Competence Scale                        1   2       3      4
     Age:
     Gender:          M         F
                                                          Maintains satisfying lifestyle
     Nationality:________________________                 Fulfills role expectations
     Ethnicity:
         Caucasian
                                                          Works toward goals
         Black/African origin                             Meets personal performance standards
         Asian/Pacific Islander
         American Indian or Alaskan Native                Organizes time for responsibilities
         Hispanic
         Multiracial                                      Participates in interests
        Other___________________________
                                                          Fulfilled roles (past)
         Unknown
     Years of Education:                                  Maintained habits (past)
                                                          Achieved satisfaction (past)
     Degree(s) Earned:
                                                          Occupational Behavior Settings Scale                 1   2       3      4
     Employment Status:
          Employed                    Volunteer           Home-life occupational forms
          Student                     Retired             Major productive role occupational forms
          Homemaker                   Unemployed
          Caregiver                   Other               Leisure occupational forms
     Living Situation:
          Lives alone
                                                          Home-life social group
          Assisted living                                 Major productive social group
          Institution (e.g., nursing home > 6 months)
          Lives with family                               Leisure social group
          Lives with friend/roommate
          Other ______________________________            Home-life physical spaces, objects and resources
     Independence in Occupational Behavior:
                                                          Major productive role physical spaces, objects
          Independent
                                                          and resources
          Needs assistance
         Totally dependent                                Leisure physical spaces, objects and resources
     Main Disabling Condition
                                                         Key:    4 = Exceptionally competent occupational functioning;
                                                         3 = Appropriate, satisfactory occupational functioning; 2 = Some
                                                         occupational dysfunction; 1 = Extremely occupationally dysfunctional



OPHI-II Data Summary Sheet                                                                                               Version 2.1

				
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