About the Individual: Record Booklet Name: Telephone: Current or Highest Grade Completed (if applicable):. School or Other Facility (if applicable):_ Language Spoken at Home:_ Does the individual have any disabling conditions? _ Sex (circle one): F M Year Month Day Test Date: _ _ _ Birth Date: Chronological Age: \/ineland-E Vineland Adaptive Behavior Scales, Second Edition Parent/Caregiver Rating Form About the Respondent: . :-Name:__- ■;" - - -~ Relationship to Individual:^ Telephone: PEARSON Copyright © 2005 NCS Pearson, Inc. All rights reserved. Product Number: 31013 Directions: This booklet contains phrases that describe many different behaviors that people show at home, school, work, or other settings. The behaviors range from those appropriate for infants to those appropriate for adults. Some may be too hard for younger children, and some may be too easy for older children or for adults. Thus, the child, adolescent, or adult you are rating may not show all the behaviors described in the items. In each section, find the starting point ( 0-5 ) for the individual's age. Read each phrase, and mark the response that best describes the individual's behavior. The response that you choose should reflect how often the individual performs the behavior without help, when the behavior is needed. Mark your scores in this booklet by circling one response option for each item. • Circle "2" if the individual usually performs the behavior without help or reminders. • Circle "1" if the individual sometimes performs the behavior without help or reminders or partially performs the behavior without help or reminders. • Circle "0" if the individual never performs the behavior or never performs it without help or reminders. • If you have never seen the individual perform a behavior and don't know whether he or she performs it, circle "DK" for Don't Know. • If an item has a Scoring Tip, use the tip to help you decide which response option to circle. • If an item has a Scoring Tip that says you may circle "N/O" for No Opportunity, you may circle that option, if appropriate, instead of a "2," "1," "0," or "DK." • Some sections do not apply to children younger than 3 years of age. If the child you are rating is younger than the age of the first start point, do not mark any items in that section. Here is an example: 73 J3 o 0 OK DK In ihis column circle vouf rp^porr-P. Wan li nit / .Klditinnal «.( urtng inioniitltion till sulllC ill*m*> 0 t|U£'Stion m nrr the iit'in .mil thf'H UR |c Ihc question mark Continued on next page Directions continued If you want to change a response, mark an X through it, and circle your new choice If you have a question about any item, first mark the response that best describes the individual's behavior, and then circle the question mark (?) to the right of the response options. ... Use the following table to help you choose the response that best describes the behavior of the individual you are rating. RATING THE INDIVIDUAL: 2 Usually Usually performs the behavior without help or reminders when it is needed; or Performed the behavior at a younger age but now has outgrown it 1 Sometimes or Partially •'t^6raetimfes"pe'rforms^we'oen^vior^Withbut-'hclpor'.;r.cminders:vyhen;it;is-'needeg; or;-.: 0 Never Never performs the behavior without help or reminders;.or ?}. Never performs the behavior, because he or she is unable; or Never performs the behavior, because he or she is too young; or Never performs the behavior, because he or she is not allowed to; or Never performs the behavior, because he or she'has a physical disability "that prevents' the behavior Remember to respond in each section to every item after the start point for the individual's age Communication Response Options: 2 = Usually, 1 = Sometimes or Partially, 0 = Never, DK = Don't Know siariAgcs 1 Turns eyes and head toward sound. 0-4 7 > ■ 1 ,'c0fS Wm 2 Looks toward parent or caregiver when hearing parent's or caregiver's voice. 2 1 0 t)K 3 Responds to his or her name spoken (for example, turns toward speaker, smiles, etc.). Iii§iiSa|i - - - 4 Demonstrates understanding of the meaning of no, or word or gesture with the same meaning [for example, stops current activity briefly). IP Sip 5 Demonstrates understanding of the meaning of yes, or word or gesture with the same meaning (for example, continues activity, smiles, etc.). 2 1. .0. if 6 Listens to story for at least 5 minutes (that is, remains relatively still and directs attention to the storyteller or reader). 7 Points to at least three major body parts when asked (for example, nose, mouth, hands, feet, etc.). Stan Ages 8 Points to common objects in a book or magazine as they are named 5+ (for example, dog, car, cup, key, etc.). ■ Slip jjj 9 Listens to instructions. ^^^^^^^ 10 Follows instructions with one action and one object (for example, "Bring me the book"; "Close the door"; etc.). 11 Points to at least five minor body parts when asked (for example, fingers, elbows, teeth, toes, etc.). "DK 12 Follows instructions with two actions or an action and two objects (for example, "Bring me the crayons and the paper"; "Sit down and eat your lunch"; etc.). 13 Follows instructions in "if-then" form (for example, "If you want to play outside, then put your things away"; etc.). i ,0 ■.■■■";''V^'/Xffi'viri'-o 14 Listens to a story for at least 15 minutes. 2 . u - ■■ ■ UK 15 Listens to a story for at least 30 minutes. 16 Follows three-part instructions (for example, "Brush your teeth, get dressed, and make your bed"; etc.). 17 Follows instructions or directions heard 5 minutes before. ■ 18 Understands sayings that are not meant to be taken word for word (for example, "Button your lip"; "Hit the road"; etc.). 19 Listens to an informational talk for at least 1 5 minutes. - ■ 20 Listens to an informational talk for at least 30 minutes. 11 Circle"?" If You Have a Question Sun Ages -J Cries or fusses when hungry or wet. 0-4 2 Smiles when you smile at him or her. mm 3 Makes sounds of pleasure (for example, coos, laughs, etc.). 1 4 Makes nonword baby sounds (that is, babbles). 5 Makes sounds or gestures (for example, waves arms) to get parent's or caregiver's attention. ' i ' ' llijMif^iiii m m 6 Makes sounds or gestures (for example, shakes head) if he or she wants an activity to stop or keep going. Circle "?" II You Have a Question 5 UP __ Communication, continued sages Response Options: 2 = Usually, 1 = Sometimes or Partially, 0 = Never, DK = Don't Know 7 Waves good-bye when another person waves or parent or caregiver tells him or her to wave. 8 Says "Da-da," "Ma-ma," or another name for parent or caregiver (including parent's or caregiver's first name or nickname). 9 Points to object he or she wants that is out of reach. 10 Points or gestures to indicate preference when offered a choice (for example, "Do you want this one or that one?"; etc.). 11 Repeats or tries to repeat common words immediately upon hearing them (for example, ball, car, go, etc.). 12 Names at least three objects (for example, bottle, dog, favorite toy, etc.). 13 Says one-word requests (for example, up, more, out, etc.). 14 Uses first names or nicknames of brothers, sisters, or friends, or says their names when asked. 15 Answers or tries to answer with words when asked a question. 16 Names at least 10 objects. 17 States own first name or nickname (for example, Latesha, Little Sister, etc.) when asked. 18 Uses phrases with a noun and a verb (for example, "Katie stay"; "Co home"; etc.). 19 Asks questions by changing inflection of words or simple phrases ("Mine?"; "Me go?"; etc.); grammar is not important. 20 Says at least 50 recognizable words. 21 Uses simple words to describe things (for example, dirty, pretty, big, loud, etc.). 22 Asks questions beginning with what or where (for example, "What's that?"; "Where doggie go?"; etc.). 23 Uses negatives in sentences (for example, "Me no go"; "I won't drink it"; etc.); grammar is not important. 24 Tells about experiences in simple sentences (for example, "Ginger and I play"; "Dan read me a book"; etc.). SianAgos 25 Says correct aee when asked. 5-13 _'________ 26 Says at least 100 recognizable words. 27 Uses in, on, or under in phrases or sentences (for example, "Ball go under chair"; "Put it on the table"; etc.). 28 Uses and in phrases or sentences (for example, "Mom and Dad"; "I want ice cream and cake"; etc.). 29 Says first and last name when asked. 30 Identifies and names most common colors (that is, red, blue, green, yellow, orange, purple, brown, and black). Mark a "2" if the individual names 6 to 8 colors; mark a "1" if the individual names 2 to 5 colors; mark a "0" if the individual names 0 or 1 color. 31 Asks questions beginning with who or why (for example, "Who's that?"; "Why do I have to go?"; etc.). 32 Uses present tense verbs ending in ing (for example, "Is singing"; "Is playing"; etc.). DK 111 III •2 U DK SlillilDK1 i\ *»__ mm s HI Circle "?" If You Have a Question c Communication, continued Response Options: 2 = Usually, 1 = Sometimes or Partially, 0 = Never, DK = Don't Know 33 Uses possessives in phrases or sentences (for example, "That's her book"; "This is Carlos's ball"; etc.). 34 Uses pronouns in phrases or sentences; must use correct gender and form of the pronoun, but sentences need not be grammatically correct (for example, "He done it"; "They went"; etc.). 35 Asks questions beginning with when (for example, "When is dinner?"; "When can we go home?"; etc.). 36 Uses regular past tense verbs (for example, walked, baked, etc.); may use irregular past tense verbs ungrammatically (for example, "I runned away"; etc.; Start Ages 14+ 40 Says month and day of birthday when asked. 44 Uses between in phrases or sentences (for example, "The ball went between the cars; etc.). 45 Says own telephone number when asked. 46 Easily moves from one topic to another in conversation. PSBI1I 37 Uses behind or in front of in phrases or sentences (for example, "I walked in front of her"; "Terrell is behind you"; etc.). 38 Pronounces words clearly without sound substitutions (for example, does not say "wabbit" for "rabbit," "Thaily" for "Sally," etc.). 39 Tells basic parts of a story, fairy tale, or television show plot; does not need to include great detail or recount in perfect order. 41 Modulates tone of voice, volume, and rhythm appropriately (for example, does not consistently speak too loudly, too softly, or in a monotone, etc.). 42 Tells about experiences in detail (for example, tells who was involved, where activity took place, etc.). 43 Gives simple directions (for example, on how to play a game or how to make something). f|HMHflB£9 Mark a "2" if the directions are clear enough to follow; mark a "1" if ihe Brfflffliffirisfflffi"^ individual articulates directions but they are not clear enough to follow; mark a "0" if the individual never attempts to articulate directions. 47 Stays on topic in conversations; does not go off on tangents. 48 Explains ideas in more than one way (for example, "This was a good book. It was exciting and fun to read"; etc.). 49 Has conversations that last 1 0 minutes (for example, relates experiences, contributes ideas, shares feelings, etc.). 50 Uses irregular plurals correctly (for example, children, geese, mice, women, etc.). 51 Says complete home address (that is, street or rural route, apartment number, city, and state), with or without zip code, when asked. 52 Describes a short-term goal and what he or she needs to do to reach it (for example, says, "I want to get an A on my test, so I'm going to study hard"; etc.). 53 Gives complex directions to others (for example, to a distant location, for recipe with many ingredients or steps, etc.). gra^KBSB Mark a "2" if the directions are clear enough to follow; mark a "1" if the SSSU^aSMSs individual articulates directions but they are not clear enough to follow; mark a "0" if the individual never attempts to articulate directions. 54 Describes a realistic long-range goal that can be done in 6 months or more (for example, says, "I want to buy a bike, so I'll babysit and run errands to earn enough money to buy it"; etc.). Circle "?" If You Have a Question 7 Start Ages 3-13 Communication, continued Response Options: 2= Usually, 1 = Sometimes or Partially, 0= Never, DK = Don't Know 1 Identifies one or more alphabet letters as letters and distinguishes them from numbers. 2 Recognizes own name in printed form. 3 Identifies at least 10 printed letters of the alphabet. 4 Prints or writes using correct orientation (for example, in English from left to right; in some languages from right to left or top to bottom). 5 Copies own first name. 8 Prints or writes own first and last name from memory. 9 Reads at least 10 words aloud. 11 Reads simple stories aloud (that is, stories with sentences of three to five words). 12 Prints simple sentences of three or four words; may make small errors in spelling or sentence structure. 13 Prints more than 20 words from memory; may make small spelling errors. Stan Ag« 14 Reads and understands material of at least second-grade level. 14+ 15 Puts lists of words in alphabetical order. 21 Edits or corrects own written work before handing it in (for example, checks punctuation, spelling, grammar, etc.). 22 Writes advanced correspondence at least 10 sentences long; may use computer. 23 Reads and understands material of at least ninth-grade level. 24 Reads at least two newspaper articles weekly (print or electronic version). 25 Writes business letters (for example, requests information, makes complaint, places order, etc.); may use computer. Hi 6 Identifies all printed letters of the alphabet, upper- and lowercase. 7 Prints at least three simple words from example (for example, cat, see, bee, etc. 10 Prints at least 10 simple words from memory (for example, hat, ball, the, etc. 16 Writes simple correspondence at least three sentences long (for example, postcards, thank-you notes, e-mail, etc.). 17 Reads and understands material of at least fourth-grade level. 18 Writes reports, papers, or essays at least one page long; may use computer. 19 Writes complete mailing and return addresses on letters or packages. 20 Reads and understands material of at least sixth-grade level. 8S3B8&,'- Circle"?" If You Have a Question ? Star! Ages 0-8 Daily Living fife" Response Options: 2 = Usually, 1 = Sometimes or Partially, 0 = Never, DK = Don't Know 1 Opens mouth when food is offered 2 Eats solid foods (for example, cooked vegetables, chopped meats, etc.). 3 Sucks or chews on finger foods (for example, crackers, cookies, toast, etc.). 4 Drinks from a cup or glass; may spil 5 Lets someone know when he or she has wet or soiled diaper or pants (for example, points, vocalizes, pulls at diaper, etc.). 6 Feeds self with spoon; may spil 7 Sucks from straw. 8 Takes off clothing that opens in the front (for example, a coat or sweater); does not have to unbutton or unzip the clothing. 9 Pulls up clothing with elastic waistbands (for example, underwear or sweatpants). 10 Feeds self with fork; may spill. 11 Drinks from a cup or glass without spilling. 12 Feeds self with spoon without spilling. 13 Urinates in toilet or potty chair. 15 Asks to use toilet. 16 Defecates in toilet or potty chair. 1 8 Zips zippers that are fastened at the bottom (for example, in pants, on backpacks, etc.). 19 Wipes or blows nose using tissue or handkerchief. 20 Is toilet-trained during the night. 21 Puts shoes on correct feet; does not need to tie laces. 22 Fastens snaps. Stan Ages 23 Holds spoon, fork, and knife correctly. 9+ 24 Washes and dries face using soap and water. 25 Brushes teeth. Mark a "2" if the individual brushes teeth without help, including putting toothpaste on the brush, and without being told to brush; mark "1" if the individual needs help brushing or putting toothpaste on the brush or needs frequent reminders; mark "0" if the individual never brushes without help or without being reminded. 26 Buttons large buttons in front, in correct buttonholes. 27 Covers mouth and nose when coughing and sneezing. mm 14 Puts on clothing that opens in the front (for example, a coat or sweater); does not have to zip or button the clothing. 17 Is toilet-trained during the day. Mark "2" if the individual uses the toilet without help and withoul accidents; W&SBS&SBffl mark " l" if [he incividual needs help, such as with wiping, or has some accidents; mark "0" if the individual always needs help or has frequent accidents. H Circle "?" If You Have a Question 9 Daily Living, continued IK;-- Response Options: 2 = Usually, 1 = Sometimes or Partially, 0 = Never, DK = Don't Know N/O = No Opportunity 28 Buttons small buttons in front, in correct buttonholes I Mm 29 Connects and zips zippers that are not fastened at the bottom (for example, in jackets, sweatshirts, etc.). 30 Turns faucets on and adjusts temperature by adding hot or cold water. 31 Wears appropriate clothing during wet or cold weather (for example, raincoat, boots, sweater, etc.). 32 Bathes or showers and dries self. |p8§|j§jBB|Ij§ Mark a "2" if ihe individual bathes or showers without help, including araaflsBB^gilfili turning the water on anc off; mark a "1" if the individua! needs help with any part of bathing or drying or with turning the water on and off; mark "0" if the individual never bathes or showers without help or without reminders. 33 Finds and uses appropriate public restroom for his or her gender. 34 Washes and dries hair (with towel or hair dryer). 35 Cares for minor cuts (for example, cleans wound, puts on bandage, etc.). 36 Takes medicine as directed (that is, follows directions on label). 37 Uses thermometer to take own or another's temperature. 38 Seeks medical help in an emergency (for example, recognizes symptoms of serious illness or injury, such as shortness of breath, chest pain, uncontrolled bleeding, etc.). You may mark "N/O" for No Opportunity if the individual has not been in a medical emergency. 39 Follows directions for health care procedures, special diet, or medical treatments. You may mark "N/O" for No Opportunity if the individual does not have a health concern that requires special procedures, diet, or treatments. 40 Keeps track of medications (nonprescription and prescription) and refills them as needed. 41 Makes appointments for regular medical and dental checkups. 2 :'0 . DK Circle"?" If You Have a Question Stan Ages 14+ 3 Clears unbreakable items from own place at table 4 Cleans up play or work area at end of an activity (for example, finger painting, model building, etc.). 5 Puts away personal possessions (for example, toys, books, magazines, etc 6 Is careful when using sharp objects (for example, scissors, knives, etc 7 Clears breakable items from own place at table. 8 Helps prepare foods that require mixing and cooking (for example, cake or cookie mixes, macaroni and cheese, etc.). 9 Uses simple appliances (for example, a toaster, can opener, bottle opener, etc. Circle"?" If You Have a Question in --'■hist Daily Living, continued il.'- Response Options: 2= Usually, 1 = Sometimes or Partially, 0= Never, DK = Don't Know N/O = No Opportunity 1 111 Circle "?" If You Have 1 a Question 10 Uses microwave oven for heating, baking, or cooking (that is, sets time and power setting, etc.). IP P ? f8W|j§pBfpip§ You may mark "N/O" for No Opportunity if there is no microwave j .'.ísfSsĚS^EaSsi in the home. j ii ii Puts clean clothes away in proper place (for example, in drawers or closet, on hooks, etc.). UK ? 12 Uses tools (for example, a hammer to drive nails, a screwdriver to screw and unscrew screws, etc.). - v.. ft ■ ' ? 13 Washes dishes by hand, or loads and uses dishwasher. ? 14 Sweeps, mops, or vacuums floors thoroughly. ? HUjmmiUBggB Mark "2" if the individual mops, sweeps, or vacuums so well that the task frnlMifflHl does not have to redone; mark a "1" if the individual doesn't consistently complete the task well; mark a "0" if the individual never mops, sweeps, or vacuums, or does the task so poorly that it always needs to be redone. 15 Clears table completely (for example, scrapes and stacks dishes, throws away disposable items, etc.). ? 16 Uses household products correctly (for example, laundry detergent, furniture polish, glass cleaner, etc.). i ? 17 Prepares basic foods that do not need mixing but require cooking (for example, rice, soup, vegetables, etc.). ? 18 Cleans one or more rooms other than own bedroom. ? 19 Uses sharp knife to prepare food. ? 20 Uses stove or oven for heating, baking, or cooking (that is, turns burners on and off, sets oven temperature, etc.). . řič ? 21 Prepares food from ingredients that require measuring, mixing, and cooking. ? 22 Washes clothing as needed. ? 23 Performs maintenance tasks as needed (for example, replaces light bulbs, changes vacuum cleaner bag, etc.). ? 24 Plans and prepares main meal of the day. ? Stan Ages 1 Demonstrates understanding of function of telephone (for example, 1-9 pretends to talk on phone, etc.). 2 Talks to familiar person on telephone. 3 Uses TV or radio without help (for example, turns equipment on, accesses channel or station, selects program, etc.). You may mark "N/O" for No Opportunity if there is no TV or radio in the home._ 4 Counts at least 10 objects, one by one. 5 Is aware of and demonstrates appropriate behavior while riding in car (for example, keeps seat belt on, refrains from distracting driver, etc.). 6 Demonstrates understanding of the function of money (for example, says, "Money is what you need to buy things at the store"; etc.). 7 Uses sidewalk (where available) or shoulder of road when walking or using wheeled equipment (skates, scooter, tricycle, etc.). Circle"?" If You Have 3 Question 1 1 IP ar Daily Living, continued Response Options: 2 = Usually, 1 = Sometimes or Partially, 0 = Never, DK = Don't Know N/O = No Opportunity 8 Demonstrates understanding of function of clock (for example, says, "Clocks tell time"; "What time can we go?"; etc.). 9 Follows household rules (for example, no running in the house, no jumping on the furniture, etc.). 10 Demonstrates computer skills necessary to play games or start programs with computer turned on; does not need to turn computer on by self. You may mark "N/O" for No Opportunity if there is no computer in the home. 11 Summons to the telephone the person receiving a call or indicates that the person is not available. Stan Ages 12 Identifies penny, nickel, dime, and quarter by name when asked; does not need 10-15 to know the value of coins. 13 Looks both ways when crossing streets or roads. 14 Says current day of the week when asked. 15 Demonstrates understanding of right to personal privacy for self and others (for example, while using restroom or changing clothes, etc.). 16 Demonstrates knowledge of what phone number to call in an emergency when asked. 17 Tells time using a digital clock or watch. 20 Obeys traffic lights and Walk and Don't Walk signs. 21 Points to current or other date on calendar when asked. at a fast-food restaurant. 28 Obeys curfew parent or caregiver sets. 29 Watches or listens to programs for information (for example, weather report, news, educational program, etc.). You may mark "N/O" for No Opportunity if there is no TV or radio in the home. 30 Counts change from a purchase. 1S11 "0 DK DK Ď1C mmssSmm lote 18 States value of penny (1 cent), nickel (5 cents), dime (10 cents), and quarter (25 cents). 19 Discriminates between bills of different denominations (for example, refers to $1 bills, $5 bills, etc., in conversation; etc.). 22 Demonstrates understanding that some items cost more than others [for example, says, "I have enough money to buy gum but not a candy bar"; "Which pencil costs less?"; etc.). Stan Ages 23 Tells time by the half hour on analog clock (for example, 1:30, 2:00, etc.). 16+ 24 Makes telephone calls to others, using standard or cell phone. 25 Orders a complete meal in a fast-food restaurant. You may mark "N/O" for No Opportunity if the individual has never eaten 26 Carries or stores money safely (for example, in wallet, purse, money belt, etc.). 27 Tells time by 5-minute segments on analog clock (for example, 1:05, 1:10, etc.). Circle"?" IfYou Have a Question 31 Demonstrates computer skills necessary to carry out complex tasks (for example, word processing, accessing the Internet, installing software, etc.). Ell ? JE3BE3HHJ33M You may mark "N/O" for No Opportunity if there is no computer F^feWnimiB^mi in the home mĚĚm pli 32 Evaluates quality and price when selecting items to purchase. u - Épi ? 33 Obeys time limits for breaks (for example, lunch or coffee breaks, etc.). m mm ? 12 ' -Vis Daily Living, continued Response Options: 2 = Usually, 1 = Sometimes or Partially, 0= Never, DK = Don't Know N/O = No Opportunity 34 Travels at least 5 to 10 miles to familiar destination (that is, bikes, uses public transportation, or drives self). 35 Demonstrates understanding of right to complain or report legitimate problems when dissatisfied with services or situations. 36 Notifies school or supervisor when he or she will be late or absent. 37 Uses savings or checking account responsibly (for example, keeps some money in account, tracks balance carefully, etc.). 38 Travels at least 5 to 10 miles to unfamiliar destination (that is, bikes, uses public transportation, or drives self). 39 Earns money at part-time job (that is, at least 10 hours a week) for 1 year. Do not mark 1. 40 Attempts to improve job performance after receiving constructive criticism from supervisor. You may mark "N/O" for No Opportunity if the individual has not held a job._ 41 Manages own money (for example, pays most or all own expenses, uses checks or money orders for purchases as needed, etc.). 42 Has held full-time job for 1 year. Do not mark 1. 43 Budgets for monthly expenses (for example, utilities, rent, etc.). 44 Applies for and uses personal credit card responsibly (for example, does not exceed credit limit, pays on time, etc.). 0 Circle'*?" If You Have a Question 13 Social Skills and Relationships W&5 ' Response Options: 2 = Usually, 1 = Sometimes or Partially, 0 = Never, DK = Don't Know : M Circle"?" IfYou Have a Question Start Ages 1 0-4 Looks at face of parent or caregiver. ,2 1 -H fH ? 2 Watches (that is, follows with eyes) someone moving by crib or bed for 5 seconds or more. :i '}._'■ ■ ll;=-i''-'1- Ü 3 Shows two or more emotions (for example, laughs, cries, screams, etc.). 4 Smiles or makes sounds when approached by a familiar person. • 2- 1 ■ Ü til 5 Makes or tries to make social contact (for example, smiles, makes noises, etc.). ^^§SS^?J,.V--. ■■■■■'■■'■'1 'i: UK 6 Reaches for familiar person when person holds out arms to him or her. 7 Shows preference for certain people and objects (for example, smiles, reaches for or moves toward person or object, etc.). Start Ages 5-15 Start Ages 16+ 8 Shows affection to familiar persons (for example, touches, hugs, kisses, cuddles, etc.). 9 Imitates or tries to imitate parent's or caregiver's facial expressions (for example, smiles, frowns, etc.). 10 Moves about looking for parent or caregiver or other familiar person nearby. 11 Shows interest in children the same age, other than brothers or sisters (for example, watches them, smiles at them, etc.). 12 Imitates simple movements (for example, claps hands, waves good-bye, etc.). 13 Uses actions to show happiness or concern for others (for example, hugs, pats arm, holds hands, etc.). -m mm - * - 14 Shows desire to please others (for example, shares a snack or toy, tries to help even if not capable, etc.). 15 Demonstrates friendship-seeking behavior with others the same age (for example, says, "Do you want to play?" or takes another child by the hand, etc.). 16 Imitates relatively complex actions as they are being performed by another person (for example, shaving, putting on makeup, hammering nails, etc.). 17 Answers when familiar adults make small talk (for example, if asked, "How are you?" says, "I'm fine"; if told, "You look nice," says, "Thank you"; etc.). 18 Repeats phrases heard spoken before by an adult (for example, "Honey, I'm home"; "No dessert until you clean your plate"; etc.). 19 Uses words to express own emotions (for example, "I'm happy"; "I'm scared"; etc.). 20 Has best friend or shows preference for certain friends (of either sex) over others. 21 Imitates relatively complex actions several hours after watching someone else perform them (for example, shaving, putting on makeup, hammering nails, etc.). 22 Uses words to express happiness or concern for others (for example, says, "Yeah! You won"; "Are you all right?"; etc.). 23 Acts when another person needs a helping hand (for example, holds door open, picks up dropped items, etc.). 24 Recognizes the likes and dislikes of others (for example, says, "Chow likes soccer"; "Susie doesn't eat pizza"; etc.). 25 Shows same level of emotion as others around him or her (for example, does not downplay or overdramatize a situation, etc.). 26 Keeps comfortable distance between self and others in social situations (for example, does not get too close to another person when talking, etc.). IKl 1 mm mmmm Hü m i 14 tcial Skills and Relationships, contini* "'^..O-:;. .... Response Options: 2 = Usually, 1 = Sometimes or Partially, 0 = Never, DK = Don't Know Circle "?" If You Have a Question 27 Talks with others about shared interests (for example, sports, TV shows, summer plans, etc.). 28 Starts small talk when meets people he or she knows (for example, says, "How are you?"; "What's up?"; etc.). 29 Meets with friends regularly. 30 Chooses not to say embarrassing or mean things or ask rude questions in public. 31 Places reasonable demands on friendship (for example, does not expect to be a person's only friend or to have the friend always available, etc.). 32 Understands that others do not know his or her thoughts unless he or she says them. 33 Is careful when talking about personal things. 34 Cooperates with others to plan or be part of an activity (for example, a birthday party, sports event, etc.). 35 Demonstrates understanding of hints or indirect cues in conversation (for example, knows that yawns may mean, "I'm bored," or a quick change of subject may mean, "I don't want to talk about that"; etc.). 36 Starts conversations by talking about things that interest others (for example, "Tyrone tells me you like computers"; etc.). 37 Goes on group dates. 38 Goes on single dates. Sun Ages 1 Responds when parent or caregiver is playful (for example, smiles, laughs, 0-7 claps hands, etc.). 2 Shows interest in where he or she is (for example, looks or moves around, touches objects or people, etc.). 3 Plays simple interaction games with others (for example, peekaboo, patty-cake, etc.). 4 Plays near another child, each doing different things. 5 Chooses to play with other children (for example, does not stay on the edge of a group or avoid others). 6 Plays cooperatively with one or more children for up to 5 minutes. 7 Plays cooperatively with more than one child for more than 5 minutes. 8 Continues playing with another child with little fussing when parent or caregiver leaves. 9 Shares toys or possessions when asked. 5lj^*|" 10 Plays with others with minimal supervision. 11 Uses common household objects or other objects for make-believe activities (for example, pretends a block is a car, a box is a house, etc.). 12 Protects self by moving away from those who destroy things or cause injury (for example, those who bite, hit, throw things, pull hair, etc.). 13 Plays simple make-believe activities with others (for example, plays dress-up, pretends to be superheroes, etc.). mm IplilllPP im Circle"?" If You Have a Question 15 Social Skills and Relationships, continued WS Response Options: 2 = Usually, 1 = Sometimes or Partially, 0 = Never, DK = Don't Know 14 Seeks out others for play or companionship (for example, invites others home, goes to another's home, plays with others on the playground, etc.). - JÄ mm - 1 5 Takes turns when asked while playing games or sports. DK 1 6 Plays informal, outdoor group games (for example, tag, jump rope, catch, etc.). 1 -' 0 p||| Hi ipf Dk Bf 1 7 Shares toys or possessions without being asked. 1 8 Follows rules in simple games (relay races, spelling bees, electronic games, etc.). 19 Takes turns without being asked. 20 Plays simple card or board game based only on chance (for example, Co Fish, Crazy Eights, Sorry™, etc.). 21 Coes places with friends during the day with adult supervision (for example, to a shopping mall, park, community center, etc.). Stan Ages 22 Asks permission before using objects belonging to or being used by another. 16+ If 23 Refrains from entering group when nonverbal cues indicate that he or she is not welcome. 24 Plays simple games that require keeping score (for example, kickball, pickup basketball, etc.). 25 Shows good sportsmanship (that is, follows rules, is not overly aggressive, congratulates other team on winning, and does not get mad when losing). 26 Plays more than one board, card, or electronic game requiring skill and decision making (for example, Monopoly™, Cribbage, etc.). 27 Coes places with friends in evening with adult supervision (for example, to a concert, lecture, sporting event, movie, etc.). 28 Follows rules in complex games or sports (for example, football, soccer, volleyball, etc.). 29 Coes places with friends during the day without adult supervision (for example, to a shopping mall, park, community center, etc.). 30 Plans fun activities with more than two things to be arranged (for example, a trip to a beach or park that requires planning transportation, food, recreational items, etc.). 31 Goes places with friends in evening without adult supervision (for example, to a concert, lecture, sporting event, movie, etc.). Circle"?" If You Have a Question 16 11. ^ocfal Skills and Relationships, continued j| Response Options: 2 = Usually, 1 = Sometimes or Partially, 0 = Never, DK = Don't Know Sian Ages -) 1 + Changes easily from one at-home activity to another. iBf 2 Says "thank you" when given something. s 3 Changes behavior depending on how well he or she knows another person (for example, acts differently with family member than with stranger, etc.). HI 4 Chews with mouth closed. IB 5 Says "please" when asking for something. SlBlililll lii 6 Ends conversations appropriately (for example, says, "Good-bye"; "See you later"; etc.). 7 Cleans or wipes face and hands during and/or after meals. 8 Responds appropriately to reasonable changes in routine (for example, refrains from complaining, etc.). ■ 9 Says that he or she is sorry for unintended mistakes (for example, bumping into someone, etc.). 10 Chooses not to taunt, tease, or bully. •::>": 11 Acts appropriately when introduced to strangers (for example, nods, smiles, shakes hands, greets them, etc.). 12 Changes voice level depending on location or situation (for example, in a library, during a movie or play, etc.). 13 Says he or she is sorry after hurting another's feelings. 14 Refrains from talking with food in mouth. 15 Talks with others without interrupting or being rude. 16 Accepts helpful suggestions or solutions from others. 17 Controls anger or hurt feelings when plans change for reason(s) that cannot be helped (for example, bad weather, car trouble, etc.). 18 Keeps secrets or confidences for longer than one day. ■ 19 Says he or she is sorry after making unintentional mistakes or errors in judgment (for example, when unintentionally leaving someone out of a game, etc.). 20 Shows understanding that gentle teasing with family and friends can be a form of humor or affection. 21 Tells parent or caregiver about his or her plans (for example, what time he or she is leaving and returning, where he or she is going, etc.). 22 Chooses to avoid dangerous or risky activities (for example, jumping off high places, picking up a hitchhiker, driving recklessly, etc.). 23 Controls anger or hurt feelings when he or she does not get his or her way (for example, when not allowed to watch television or attend a party; when suggestion is rejected by friend or supervisor; etc.). 24 Follows through with arrangements (for example, if promises to meet someone, meets that person; etc.). 25 Stops or slays away from relationships or situations that are hurtful or dangerous (for example, being bullied or made fun of, being taken advantage of sexually or financially, etc.). :% 26 Controls anger or hurt feelings due to constructive criticism (for example, correction of misbehavior, discussion of test score or grade, performance review, etc.). 27 Keeps secrets or confidences for as long as needed. 28 Thinks about what could happen before making decisions (for example, refrains from acting impulsively, thinks about important information, etc.). :1 29 Is aware of potential danger and uses caution when encountering risky social situations (for example, binge drinking parties, Internet chat rooms, personal ads, etc.). 30 Shows respect for co-workers (for example, does not distract or interrupt others who are working, is on time for meetings, etc.). 1 ! Ill IBl Circle"?" If You Have a Question 17 -Ji Physical Activity Response Options: 2 = Usually, 1 = Sometimes or Partially, 0 = Never, DK = Don't Know N/O = No Opportunity Start Ages 0-1 1 Holds head erect for at least 15 seconds when held upright in parent's or caregiver's arms. IP Safe fest 2 Sits supported (for example, in a chair, with pillows, etc.) for at least 1 minute. 3 Sits without support for at least 1 minute. WkWĚi 4 Creeps or moves on stomach across floor. i o fill 5 Sits without support for at least 10 minutes. mm § ttl 6 Raises self to sitting position and sits without support for at least 1 minute. H 7 Crawls at least 5 feet on hands and knees, without stomach touching floor. 11 8 Pulls self to standing position. ■ — 9 Crawls up stairs. —' " i -f^ ti. Ü 10 Takes at least two steps. SP 11 Stands alone for 1 to 3 minutes. m 12 Rolls ball while sitting. §Éfi§ ■ 13 Climbs on and off low objects (for example, chair, step stool, slide, etc.). 14 Crawls down stairs. 15 Stands for at least 5 minutes. dk Start Ages 2-4 16 Walks across room; may be unsteady and fall occasionally. B 17 Throws ball. m 18 Walks to get around; does not need to hold on to anything. i ! ~ Ml 19 Climbs on and off adult-sized chair. ■ -2? : • 1 - II 20 Runs without falling; may be awkward and uncoordinated. 1 1 - 0 wm 21 Walks up stairs, putting both feet on each step; may use railing. 22 Kicks ball. 23 Runs smoothly without falling. iiill^^B 24 Walks down stairs, facing forward, putting both feet on each step; may use railing. : teg 25 Jumps with both feet off floor. í>k Ä Start Ages 5-6 26 Throws ball of any size in specific direction. 27 Catches beach bali-sized ball with both hands from a distance of 2 or 3 feet. W&ěěěěBĚě mi 28 Walks up stairs, alternating feet; may use railing. 5h9HHHHWN íép 29 Pedals tricycle or other three-wheeled toy for at least 6 feet. m i ii ;dk. BBBBMHBH You mav nark "N/O" for No Opportunity if the individual does not have a frSaBESSESuSa tricycle o- three-wheeled toy. However, if the individual nas such a vehicle but does not ride it for any reason, including parent or caregiver does not think he or she is ready, mark "0." 30 Jumps or hops forward at least three times. Í||ill§»l 31 Hops on one foot at least once without falling; may hold on to something for balance. RHiiiiSil liilispKP fill Circle "?" If You Have a Question IS m Physical Activity, continued MX Response Options: 2 = Usually, 1 = Sometimes or Partially, 0 = Never, DK = Don't Know N/O = No Opportunity Circle "?" If You Have a Question 32 Climbs on and off high objects (for example, jungle gym, 4-foot slide ladder, etc.). I m ? 33 Walks down stairs, alternating feet; may use railing. gasps m ? 34 Runs smoothly, with changes in speed and direction. IP ? 35 Rides bicycle with training wheels for at least 10 feet. 0 -UK 1 jggp|ffl|g|p|Ii You may mark "N/O" for No Opportunity if the individual does not have . reason, including parent or caregiver does not think he or she is ready, mark "0." 36 Catches beach ball-sized ball (from at least 6 feet away) with both hands. IIF MM ill ? 37 Hops forward on one foot with ease. ■ (i' ? 38 Skips at least 5 feet. Si ? 39 Catches tennis or baseball-sized ball (from at least 1 0 feet away), moving to catch it if necessary. ? 40 Rides bicycle with no training wheels without falling. ■; ? |PJggP|I|P||| You may mark "N/O" for No Opportunity if the individual does not have fMxSM&SSmm a bicycle. However, if the individual has a bike but does not ride it for any ■ ■ ■ reason, including parent or caregiver does not think he or she is ready, mark "0." m Stan Ages 5-6 3 Moves object from one hand to the other 4 Squeezes squeaky toy or object. 5 Picks up small object with thumb and fingers. 12 Completes simple puzzle of at least two pieces or shapes. 13 Turns book or magazine pages one by one. 14 Uses twisting hand-wrist motion (for example, winds up toy, screws/unscrews lid of jar, etc.). 15 Holds pencil in proper position (not with fist) for writing or drawing. 16 Colors simple shapes; may color outside lines. 17 Builds three-dimensional structures (for example, a house, bridge, vehicle, etc.) with at least five small blocks._ 18 Opens and closes scissors with one hand. Circle"?" If You Have a Question 6 Removes object (for example, a block or clothespin) from a container. 7 Puts object (for example, a block or clothespin) into a container. 8 Turns pages of board, cloth, or paper book, one at a time. 9 Stacks at least four small blocks or other small objects; stack must not fall. 10 Opens doors by turning doorknobs. 11 Unwraps small objects (for example, gum or candy). 19 Physical Activity, continued Ir. Response Options: 2= Usually, 1 = Sometimes or Partially, 0 = Never, DK = Don't Know N/O = No Opportunity 19 Clues or pastes two or more pieces together (for example, for art or science projects, etc.). 20 Uses tape to hold things together (for example, torn page, art project, etc.). 21 Draws more than one recognizable form (for example, person, house, tree, etc.). Mark a "2" if the individual draws two or more recognizable forms; mark a "1" if the individual draws one form; mark a "0" if the individual does not draw any recognizable forms 22 Makes recognizable letters or numbers. 23 Draws circle freehand while looking at example. 24 Uses scissors to cut across paper along a straight line. 25 Colors simple shapes; colors inside the lines. 27 Uses eraser without tearing paper. 28 Draws square freehand while looking at example. 29 Draws triangle freehand while looking at example. 30 Ties knot. 31 Draws straight line using a ruler or straightedge. 2 I 0 •DK J9B 0 DK H19Í mm 2 I Š ■ mmm 26 Cuts out simple shapes (for example, circles, squares, rectangles, etc.; AÉ 11» 32 Unlocks dead-bolt, key, or combination locks that require twisting. You may mark "N/O" for No Opportunity if there are no dead-bolt, key, or combination locks in the home. 33 Cuts out complex shapes (for example, stars, animals, alphabet letters, etc.). 34 Uses keyboard, typewriter, or touch screen to type name or short words; may look at keys. You may mark "N/O" for No Opportunity if there is no computer in the home._ 35 Ties secure bow. 36 Uses a keyboard to type up to 10 lines; may look at the keys. You may mark "N/O" for No Opportunity if there is no computer in [he home. Circle "?" If You Have a Question 20