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35
Questions
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1
Client's Full Name
*
This field is required.
First Name
Last Name
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2
Informant
First Name
Last Name
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3
Interviewer
First Name
Last Name
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4
Date
*
This field is required.
-
Date
Month
Day
Year
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5
Informant-Client Relationship: Indicate your relationship to the person
*
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Parent
Instructor
Therapist/Residential Staff
Other
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6
How long have you known the person? (Years & Months)
# of years, # of months
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7
Do you interact with the person daily?
*
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Yes
No
Other
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8
In what situations do you usually interact with the person?
*
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Meals
Academic training
Leisure
Work or vocational training
Self-care
Other
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9
Aggression
*
This field is required.
If none, please put N/A
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10
Self-injury
*
This field is required.
If none, please put N/A
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11
Stereotype
*
This field is required.
If none, please put N/A
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12
Property destruction
*
This field is required.
If none, please put N/A
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13
Other
If none, please put N/A
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14
Frequency:
*
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Please Select
Hourly
Daily
Weekly
Less often
Please Select
Hourly
Daily
Weekly
Less often
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15
Severity:
*
This field is required.
Please Select
Mild: Disruptive but little risk to property or health
Moderate: Property damage or minor injury
Severe: Significant threat to health or safety
Please Select
Mild: Disruptive but little risk to property or health
Moderate: Property damage or minor injury
Severe: Significant threat to health or safety
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16
Situations in which the problem behavior is most likely to occur: Days/Times | Settings/Activities | Persons present:
Explain thoroughly here
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17
What is usually happening to the person right BEFORE the problem behavior occurs?
Explain thoroughly here
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18
What usually happens to the person right AFTER the problembehavior occurs?
Explain thoroughly here
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19
Current treatments
If none, kindly put N/A
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20
Does the problem behavior occur when theperson is not receiving attention or when caregivers are paying attention to someone else?
Please Select
Yes
No
N/A
Please Select
Yes
No
N/A
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21
Does the problem behavior occur when the person’s requests for preferred items or activities are denied or when these are taken away?
Please Select
Yes
No
N/A
Please Select
Yes
No
N/A
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22
When the problem behavior occurs, do caregivers usually try to calm the person down orinvolve the person in preferred activities?
Please Select
Yes
No
N/A
Please Select
Yes
No
N/A
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23
Is the person usually well behaved when (s)heis getting lots of attention or when preferred activities are freely available?
Please Select
Yes
No
N/A
Please Select
Yes
No
N/A
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24
Does the person usually fuss or resist when(s)he is asked to perform a task or to participatein activities?
Please Select
Yes
No
N/A
Please Select
Yes
No
N/A
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25
Does the problem behavior occur when theperson is asked to perform a task or to participate in activities?
Please Select
Yes
No
N/A
Please Select
Yes
No
N/A
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26
If the problem behavior occurs while tasks arebeing presented, is the person usually given a“break” from tasks?
Please Select
Yes
No
N/A
Please Select
Yes
No
N/A
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27
Is the person usually well behaved when (s)heis not required to do anything?
Please Select
Yes
No
N/A
Please Select
Yes
No
N/A
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28
Does the problem behavior occur even when noone is nearby or watching?
Please Select
Yes
No
N/A
Please Select
Yes
No
N/A
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29
Does the person engage in the problem behavior even when leisure activities are available?
Please Select
Yes
No
N/A
Please Select
Yes
No
N/A
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30
Does the problem behavior appear to be a form of “self-stimulation?”
Please Select
Yes
No
N/A
Please Select
Yes
No
N/A
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31
Is the problem behavior less likely to occurwhen sensory stimulating activities arepresented?
Please Select
Yes
No
N/A
Please Select
Yes
No
N/A
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32
Is the problem behavior cyclical, occurring forseveral days and then stopping?
Please Select
Yes
No
N/A
Please Select
Yes
No
N/A
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33
Does the person have recurring painfulconditions such as ear infections or allergies?
Please Select
Yes
No
N/A
Please Select
Yes
No
N/A
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34
Is the problem behavior more likely to occur when the person is ill?
Please Select
Yes
No
N/A
Please Select
Yes
No
N/A
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35
If the person is experiencing physical problems,and these are treated, does the problem behaviorusually go away?
Please Select
Yes
No
N/A
Please Select
Yes
No
N/A
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36
SCORING SUMMARY
PROVIDER USE ONLY
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37
SCORE TOTAL
Total and Potential Source of Reinforcement
Item's circles "Yes" and potential source
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