ABAS-3
Adult Form Ages 16-89
Name of client
*
First Name
Last Name
Name of person filling out this form
*
First Name
Last Name
Communication
Completing the ABAS-3– read through this entire packet and indicate if the child/ person that you are rating is able to do the different items that are listed. A 3 indicates that the child can do the task with no issues or help from another; a 2 means they need a little help; a 1 means they need a lot of help to do the task, and a 0 means they do not do it by them self at all. Some of the things they may not be able to do yet, indicate that as 0. Please indicate an answer even if you check the box that indicates that you are guessing. Please respond to all of the items. If you have any question’s please email jotforms@sabintn.com.
1. Says the names of other people (for example, "Mama,"" Daddy," or names of friends).
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
2. Says "Hello'' and "Good-bye" to others.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
3. Answers the telephone by saying "Hello.''
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
4. Uses sentences with a noun and verb.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
5. Names 20 or more familiar objects.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
6. States his or her home address. including zip code.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
7. Gives verbal instructions to others that involve two or more steps or activities.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
8. Speaks clearly and distinctly.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
9. States his or her telephone number.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
10. Shakes head or says ''Yes" or "No" in response to a simple question (for example, "Do you want something to drink?").
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
11. Looks at other people's faces when they are talking to him or her.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
12. Says irregular plural nouns correctly (for example, says "'feet" instead of "foots" and" men" instead of "mans").
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
13. Nods or smiles to encourage others when they are talking.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
14. Tells family, friends, or others about his or her favorite activities.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
15. Listens closely for at least 5 minutes when people talk.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
16. Uses up-to-date information to discuss current events.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
17. Starts conversations on topics of interest to others.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
18. Answers complex questions that require careful thought and opinion (for example, questions about politics or current events).
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
19. Distinguishes truthful from exaggerated claims by friends, advertisers, or others.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
20. Repeats stories or jokes correctly after hearing them from others.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
21. Talks with others about complex topics for at least 10 minutes (for example, about politics or current events).
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
22. Waits for others to finish what they are saying, without interrupting.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
23. Participates in conversations without talking too much or too little.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
24. Talks about realistic future educational or career goals.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
25. Explains the terms of a legal document to others (for example, a contract to buy a house or rent a car).
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
Community Use
1. Finds the restroom in public places.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
2. Finds a specific area in a store or business (for example, dairy aisle in a store or customer service department in a bank).
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
3. Looks both ways before crossing a street or parking lot.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
4. Orders own meals when eating out.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
5. Carries personal identification when traveling to nearby places in the community.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
6. Relies on himself or herself for travel in the community (for example. walks or uses public transportation, a bicycle, or a car).
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
7. Carries enough money to make small purchases (for example. a soft drink).
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
8. States the general address of a travel destination (for example. "On Washington Avenue, near Lake Street").
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
9. Recognizes when a store item is poorly made or too expensive.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
10. Asks a store clerk for help if an item cannot be found.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
11. Tells others about a store's hours of operation (for example. "10 a.m. to 9p.m.").
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
12. Follows another person's directions to nearby places.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
13. Uses a credit or debit card for making purchases.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
14. Makes appointments by telephone, mobile device, or Internet.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
15. Uses paper or digital maps to find his or her way to desired locations.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
16. Obtains money from an ATM.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
17. Before buying an item in a store, gives careful thought to the need for it and its cost.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
18. Calls a repairperson when needed (for example, if the air conditioner or heater stops working).
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
19. Is responsible for his or her personal finances, such as bank account, credit card, or utility bill.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
20. Asks other people's advice on where to shop.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
21. Uses the school library, public library, or Internet to get books or reference materials.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
22. Shops for friends or family who may be unable to shop.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
23. Uses printed or Internet resources to obtain information before making major purchases {for example, cars, appliances, computers).
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
24. Walks or rides bike alone to locations within a 1-mile or 5-block radius of home or work.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
Functional Academics
1. Writes or prints his or her first and last name.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
2. States the days of the week in order.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
3. Reads his or her name when printed.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
4. Writes his or her address, including zip code.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
5. Reads menus at restaurants.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
6. Gives a clerk the necessary amount of money when buying items.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
7. Reads and obeys common signs (for example, Do Not Enter, Exit, Stop).
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
8. Locates telephone numbers using a phone book or the Internet.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
9. Locates important dates on a calendar (for example, birthdays or holidays).
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
10. Weighs self or objects correctly using a scale.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
11. Finds names and telephone numbers for repair services or businesses using a phone book or the Internet.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
12. Reads and follows a daily classroom or work schedule, without needing to be reminded by another person.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
13. Records dates and times for appointments and deadlines.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
14. Measures length and height.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
15. Writes and sends letters, personal notes, or emails.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
16. Checks for correct change after buying an item.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
17. Uses lists and reminders to remember important things.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
18. Completes written forms to apply for jobs.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
19. Completes forms for businesses or services (for example. to obtain a lease).
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
20. Checks the accuracy of charges before paying a bill.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
21. Reads important documents (for example, credit card applications or rental agreements).
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
22. Budgets money to cover expenses for at least 1 week.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
23. Reads labels before purchasing products for important information about size, weight, and directions for use.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
24. Checks bank or other financial statements at least monthly to be sure they are correct.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
Home Living
1. Operates a microwave oven.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
2. Uses small electrical appliances (for example, a can opener or blender).
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
3. Makes simple meals that require no cooking (for example, sandwiches or salads).
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
4. Cooks simple foods on a stove (for example, eggs or canned soup).
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
5. Wipes up spills at home.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
6. Shows respect when using others' possessions (for example, by keeping them clean and returning them undamaged when requested).
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
7. Uses a clothes dryer.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
8. Uses a washing machine to wash clothes.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
9. Washes dishes either by hand or with a dishwasher.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
10. Places dirty clothes in the proper place (for example, a hamper or clothes basket).
*
1 Is not able
2 Never (or almost never)
3 Sometimes when needed
4 Always (or almost always)
11. Folds clean clothes.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
12. Assists in big cleanup projects at home or work (for example, spring cleaning or cleaning storage rooms).
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
13. Keeps working on important tasks at home, even when it is noisy.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
14. Takes out trash when can is full.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
15. Clears the table completely after a meal.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
16. Puts things in their proper place when finished using them.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
17. Cleans his or her room or living quarters regularly.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
18. Cleans bathroom with proper cleaning supplies.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
19. Makes his or her bed.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
20. Pays bills on time (for example, electricity or telephone bills).
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
21. Dusts furniture until it is clean.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
22. Follows a maintenance schedule for car or home (for example, changes the car engine oil or the home furnace filter).
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
23. Obtains home, rental, or car insurance for himself or herself.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
24. Performs minor household repairs (for example, fixes a clogged drain or leaky faucet).
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
Health and Safety
1. Uses electrical outlets or sockets safely.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
2. Shows caution around hot or dangerous items.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
3. Carries breakable objects safely and carefully.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
4. Displays safe behaviors at work or other public places.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
5. Buckles own seat belt in a car.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
6. Cares for own minor injuries (for example, paper cuts, knee scrapes, nosebleeds).
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
7. Swallows liquid medicines as needed.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
8. Carries scissors safely.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
9. Follows general safety rules at home.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
10. Uses tools and equipment safely.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
11. Refuses gifts and rides from strangers.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
12. Obeys requests from other people only if he or she knows and trusts them.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
13. Avoids people who might take advantage of him or her (for example, for money or sex).
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
14. Takes medications without supervision on days and at times prescribed.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
15. Buys over-the-counter medications when needed for illness.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
16. Reads labels on his or her medications to make sure they have not expired.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
17. Takes temperature with a thermometer when feeling sick.
*
0 Is not able
1 Never (or almost never)
Sometimes when needed
3 Always (or almost always)
18. Inspects contents of refrigerator and removes food that is spoiled or whose expiration date has passed.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
19. Makes his or her own appointments to see a physician for annual checkups.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
20. Plans meals in order to get necessary nutrition.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
Leisure
1. Waits for his or her turn in games and other fun activities.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
2. Follows the rules in games and other fun activities.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
3. Selects television programs or uses the Internet to keep up with an area of interest (for example, sports, music, nature).
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
4. Listens to music for fun and relaxation.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
5. Plays with games or other fun items with others.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
6. Invites others to join him or her in playing games and other fun activities.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
7. Engages in a variety of fun activities instead of only one or two.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
8. Attends fun community activities with others (for example. a movie or concert).
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
9. Attends fun activities at another's home.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
10. Tells others when he or she needs free time to relax alone.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
11. Plays alone with games or does other fun activities.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
12. Initiates games or selects television programs liked by friends or family members.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
13. Plans ahead for fun activities on free days or afternoons.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
14. Plans ahead for extended leisure activities during breaks or vacations.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
15. Tries a new activity to learn about something new.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
16. Organizes a game or other fun activity for a group of friends without help from others.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
17. Invites others home for a fun activity.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
18. Makes travel arrangements for self and others.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
19. Reserves tickets in advance for activities such as concerts or sports events.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
20. Has a hobby or creative activity that requires making or building something (for example, sewing, carpentry, gardening).
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
21. Joins an organized group without help from another person (for example, a club, sports team, or musical group).
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
22. Participates in an organized program for a sport or hobby (for example, practices basketball or takes a music class).
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
Self-Care
1. Puts shoes on the correct feet.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
2. Buttons own clothing.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
3. Uses a fork to eat solid food.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
4. Uses restroom at home without help.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
4 Always (or almost always)
5. Closes and locks the door before using public restrooms.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
6. Fastens and straightens clothing before leaving restroom.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
7. Dresses himself or herself.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
8. Washes hands with both soap and water.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
9. Uses public restroom alone.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
10. Blows and wipes nose with tissue or handkerchief.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
11. Combines hot and cold water for a shower or bath.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
12. Ties his or her own shoes.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
13. Selects correct clothes for cold or warm days.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
14. Brushes teeth before leaving for work or appointments.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
15. Cuts or files his or her own fingernails and toenails regularly.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
16. Selects appropriate clothes for different occasions (for example, casual activities or formal events).
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
17. Bathes daily.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
18. Keeps hair neat during the day by brushing or combing.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
19. Cuts meats or other foods into bite-size pieces with a knife.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
20. Eats a variety of foods instead of preferring only one or two.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
21. Gets out of bed on time by himself or herself.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
22. Wears a variety of clothes, instead of the same or similar clothes most days.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
23. Obtains haircuts regularly on his or her own.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
24. Washes and rinses sink after brushing teeth.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
25. Avoids unhealthy foods and drinks.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
26. Exercises or works out at least 2 hours weekly.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
Self-Direction
1. Works on one home or school activity for at least 15 minutes without reminders.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
2. Works independently and asks for help only when necessary.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
3. Personally calls work or other places if absent.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
4. Avoids situations at home or in the neighborhood that are likely to result in trouble.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
5. Resists pressure from others to do things that could endanger him or her.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
6. Stops a fun activity without complaining, when time is up.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
7. Stands still when needed, without fidgeting or moving around.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
8. Controls disappointment when a favorite activity is canceled.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
9. Controls anger when another person breaks the rules in games and other 0fun activities.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
10. Completes routine household tasks within a reasonable amount of time.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
11. Returns on time when asked to be back in 1 hour.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
12. Saves money to buy something special (for example, a birthday present or special clothes).
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
13. Refuses when another person asks him or her to do something foolish.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
14. Routinely arrives at places on time.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
15. Keeps working on hard tasks without becoming discouraged, quitting or needing reminders.
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
16. Controls temper when disagreeing with friends.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
17. Avoids behavior that could embarrass or bring shame to self or family.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
18. When leaving home, informs others of destination and return time.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
19. Controls feelings when not getting his or her own way.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
20. Plans home projects in logical steps.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
21. Makes important decisions only after careful consideration, without rushing.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
22. Calls family or others when he or she will be late (for example. in returning home, attending a social event, or arriving for an appointment).
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
23. Plans ahead to allow enough time to complete big projects.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
24. Limits time playing computer games or other nonproductive activities.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
25. Completes large home projects on time.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
Social
1. Says "Thank you" when given a gift.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
2. Has one or more friends.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
3. Stands a comfortable distance from others during conversations (not too close).
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
4. Laughs in response to funny comments or jokes.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
5. Moves out of the way of other people as needed on sidewalks, in store aisles, or in hallways.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
6. Congratulates others when something good happens to them.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
7. Shows respect for persons in authority by following their rules and directions (for example, parents, teachers, police officers).
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
8. Shows sympathy for others when they are sad or upset.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
9. Listens to friends or family members who need to talk about problems.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
10. Recognizes when someone is making an unreasonable request.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
11. Places reasonable demands on friends (for example, does not become upset when a friend goes out with another friend).
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
12. Keeps a stable group of friends.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
13. Says "Please" when asking for something.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
14. Has good relationships with family members.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
15. Avoids friends and social settings that may be harmful or dangerous.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
16. Offers guests food or beverages.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
17. Shows good judgment in selecting friends.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
18. Seeks friendships with others in his or her age group.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
19. States when others seem happy, sad, scared, or angry.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
20. Refrains from saying or doing things that might embarrass or hurt others.
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
21. Personally makes or buys gifts for family members on birthdays or major holidays.
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
22. Tries to please others by doing something special or giving them a surprise.
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
23. Selects specific locations for social activities with friends (for example, restaurants or movie theaters).
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
24. Says when he or she feels happy, sad, scared, or angry.
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
25. Sends thank-you notes or emails after receiving a gift or help with an important task.
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
Work
Complete this skill area if the individual being rated holds a part-time or full-time job.
1. Behaves safely at work so that no one will be harmed.
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
2. Cares properly for work supplies and equipment.
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
3. Follows daily work schedule without reminders from supervisor.
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
4. Returns to work willingly after taking a break or lunch.
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
5. Performs tasks at work neatly.
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
6. Follows supervisor's instructions when completing tasks or activities.
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
7. Refuses when a coworker encourages him or her to do shoddy or unsafe work.
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
8. Cleans up area after completing work.
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
9. Is productive and cooperative as part of groups or teams.
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
10. Completes work assignments within required time limits.
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
11. Works quietly, without disturbing coworkers.
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
12. Asks for directions, as needed, before beginning work tasks.
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
13. Finds full-time or part-time jobs for himself or herself.
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
14. Organizes tasks at work so that the most important are completed first.
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
15. Takes the time needed to do a task well, without rushing.
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
16. Checks own work to determine if improvements are needed.
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
17. Keeps working efficiently and accurately, even with loud noises or distractions.
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
18. Performs extra work on the job willingly.
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
19. Seeks help from supervisor, as needed, when work-related problems or questions arise.
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
20. Shows a positive attitude toward job.
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
21. Keeps a stable part-time or full-time job for at least 1 year.
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
22. Verifies wages to ensure that he or she is receiving the proper amount.
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
23. Makes suggestions to supervisors (for example, how to have a safer or more productive workplace).
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
24. Trains and supervises others in the workplace.
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
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