Date & Time Start
*
/
Month
/
Day
Year
Date
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
05
10
15
20
25
30
35
40
45
50
55
Minutes
AM
PM
AM/PM Option
Total Time
*
Name
First Name
Last Name
Email
example@example.com
Supervisor
Selma Martinez, BCBA
Prepared
1. Materials ready, organized
*
Yes
No
N/A
NA1
2. Environment sanitized from reinforcers
*
Yes
No
N/A
NA2
3. Physical set-up appropriate (i.e., sitting-on chair, diagonal)
*
Yes
No
N/A
NA3
4. Ready to take data (logged in, data sheet open)
Yes
No
N/A
NA4
5. Reads prior therapist/supervisor notes
Yes
No
N/A
NA5
DIVISOR
Calculation
Should be Empty: