Item

Description

Notes/examples on your particular student (you will complete this section if the item is applicable to your student)

Intervention (describe one specific thing you would do to address this need)

1

Has difficulty recognizing the feelings and thoughts of others (mindblindness)

2

Uses poor eye contact

3

Has difficulty maintaining personal space, physically intrudes on others

4

Lacks tact or appears rude

5

Has difficulty keeping and making friends

6

Has difficulty joining an activity

7

Is naïve, easily taken advantage of, or bullied

8

Tends to be less involved in group activities than most same-age individuals

9

Has difficulty understanding others’ nonverbal communication

10

Has difficulty understanding jokes

11

Other (describe)

12

Expresses strong need for routine or “sameness”

13

Expresses desire for repetition

14

Has eccentric or intense preoccupations or absorption in own unique interests

15

Asks repetitive questions

16

Seems to be unmotivated by customary rewards

17

Displays repetitive motor movements (e.g. hand flapping, paces, flicks fingers in front of eyes)

18

Has problems handling transition and change

19

Has strong need for closure or difficulty stopping a task before it is completed

20

Other: describe

21

Makes sounds or states words or phrases repeatedly (non-echolalic), such as humming, “well actually”

22

Makes up new words or creates alternate meanings for words or phrases

23

Displays immediate or delayed echolalia (e.g. recites lines from movies, repeats questions or statements, etc)

24

Interprets words or conversations literally, has difficulty understanding figurative language

25

Has difficulty with rules of conversations (e.g interrupts others, asks inappropriate questions, makes poor eye contact, difficulty maintaining conversations)

26

Fails to initiate or respond to social greetings

27

Has difficulty using gestures and facial expressions

28

Has difficulty starting, joining, and or ending a conversation

29

Has difficulty asking for help

30

Makes irrelevant comments

31

Has difficulty expressing thoughts and feelings

32

Speaks in an overly formal way

33

Gives false impression of understanding more than he/she actually does

34

Talks incessantly, little back-and-forth

35

Uses an advanced vocabulary

36

Uses mechanical, “sing-song” voice or speech sounds unusual in other ways (e.g. prosody, cadence, tone)

37

Has difficulty following instruction

38

Has difficulty understanding language with multiple meanings, humor, sarcasm, or synonyms

39

Has difficulty talking about others’ interests

40

Notes on your particular student (you will complete this section if the item is applicable to your student)

41

Responds in an unusual manner to sounds (e.g. ignores sounds or overreacts to sudden, unexpected noises, high-pitched continuous sounds, or complex/multiple noises)

42

Responds in an unusual manner to pain (e.g. overreacts or seems unaware of illness or injury)

43

Responds in an unusual manner to taste (e.g. resists certain textures, flavors, brands)

44

Responds in an unusual manner to light or color (e.g. focuses on shiny items, shadows, reflections, shows preference or strong dislike for certain colors)

45

Responds in an unusual manner to temperature

46

Responds in an unusual manner to smells (e.g. may comment on smells that others do not detect)

47

Seeks activities that provide touch, pressure, or movement (e.g swinging, hugging, pacing)

48

Avoids activities that provide touch, pressure, or movement (e.g. resists wearing certain types of clothing, strongly dislikes to be dirty, resists hugs)

49

Makes noises such as humming or singing frequently

50

Other: Describe

51

Displays extensive knowledge in narrow areas of interest

52

Displays poor problem solving skills

53

Has poor organizational skills

54

Withdraws into complex, inner worlds/fantasizes often

55

Is easily distracted by unrelated details—has difficulty knowing what is relevant or makes off-topic comments

56

Displays weaknesses in reading comprehension with strong word recognition

57

Knows many facts and details but has difficulty with abstract reasoning (i.e, weak central coherence)

58

Has difficulty applying learned skills in new settings

59

Has academic skill deficits

60

Has attention problems

61

Displays very literal understanding of concepts

62

Recalls information inconsistently (i.e. seems to forget previously learned information)

63

Has difficulty understanding the connection between behavior and resulting consequences

64

65

Has balance difficulties

66

Resists or refuses handwriting tasks

67

Has poor handwriting

68

Has poor motor coordination (e.g. accident prone, difficulty using fasteners)

69

Writes slowly

70

Displays atypical activity level (e.g. over-active/hyperactive or under-active/hypoactive)

71

Has athletic skills deficits

72

Displays an awkward gait

73

Displays unusual body postures and movements or facial expressions (e.g. odd postures, stiffness, “freezing,” facial grimacing)

74

Has difficulty starting or completing actions (e.g. may rely on physical or verbal prompting by others)

75

76

Is easily stressed—worries obsessively

77

Appears to be depressed or sad

78

Has unusual fear responses (e.g. lacks appropriate fears or awareness of danger or is overly fearful)

79

Appears anxious

80

Exhibits rage reactions or “meltdowns”

81

Injures self (e.g bangs head, picks skin, bites nails until they bleed, bites self)

82

Makes suicidal comments or gestures

83

Displays inconsistent behaviors

84

Has difficulty tolerating mistakes

85

Has low frustration tolerance

86

Has low self-esteem, makes negative comments about self

87

Has difficulty identifying, quantifying, expressing and/or controlling emotions (e.g. expresses emotions only in extremes, or emotionally “flat”)

88

Has a limited understanding of own and others’ emotional responses

89

Has difficulty managing stress and/or anxiety

90

Activity

Skills/STO

Structure/

Modifications

Reinforcement

Sensory Strategies

Social Skills Communication

Data Collection

Generalization

Independent Work

Group Work

Tests

Lectures

Homework

Time

Activity

Targeted Skills to Teach

Structure/ Modifications

Reinforcement

Sensory Strategies

Communication/ Social Skills

Data Collection

Generalized Plan

Item

Description

Notes/examples on your particular student (you will complete this section if the item is applicable to your student)

Intervention (describe one specific thing you would do to address this need)

Appears to be unresponsive to others (e.g., unaware of presence of others)

Does not use sustained and purposeful eye contact or watch faces intensely

Does not respond to others’ attempts to share attention through eye gaze or pointing

Shows little curiosity about or interest in the immediate environment-appears to be in “own world”

Shows little interest in or response to positive social communication/initiations (e.g., cheerful/playful voice or baby-talk)

6

Does not calm or quiet in response to a familiar adult’s face or voice

7

Does not respond to the emotional expressions of familiar others

8

Has difficulty imitating simple movements and sounds

9

Does not use movement, sound, or gestures to gain attention of caregivers

10

Responds in an unusual manner to affection (e.g., resists hugs, or overreacts when others offer comfort)

11

Has difficulty using and perceiving nonverbal communication (e.g., tone of voice, gestures, facial expressions)

12

Treats others as if they were objects/solely to gain assistance or a desired object (e.g., pulls parent to door)

13

Has difficulty taking turns in play or social activities-social reciprocity (e.g., peek-a-boo, pat-a-cake)

14

Isolates self from others or chooses solitary play consistently and across settings

15

Does not exhibit fear of unfamiliar people-fails to display “stranger anxiety”

16

Does not seek others’ attention in order to share an experience (e.g., bring an object to show or point out an item or person)

17.

Has difficulty joining an activity with peers

18.

Makes no attempt to comfort others who are in obvious distress

19.

Does not show interest or shows little interest in interacting with peers

20.

Displays unusual eye contact (e.g., looks out of corner of eye or away from speaker)

21.

Has little or no interest in assuming “roles” in play interactions with others (e.g., “cooking” play pizza for peer at table) or between play objects (e.g., conversations between mom and dad dolls)

22.

Other

:

23

Seems unmotivated by customary rewards or social approval (e.g., stickers, praise, hug, smile)

24

Stares intensely and for long periods of time at objects that move (e.g., stares at fan or rolling credits of television show/movie)

25

Attached to objects in an unusual manner (e.g., refuses to leave the house without a block, goes to bed while holding a plastic letter of the alphabet)

26

Uses objects in repetitive, atypical manner (e.g., meticulously lines up object, spins objects repeatedly)

27

Has intense preoccupations (e.g., trains, letters, shapes, electronics, doors)-to the exclusion of play or family activities-and is difficult to distract

28

Displays atypical repetitive motor movements (e.g., flaps hands, rocks body side-to-side, flicks fingers)

29

Displays difficulty engaging in activities other than intense special interests

30

Has excessive difficulty transitioning from a preferred activity

31

Has strong need for closure or difficulty stopping a task before it is completed

32

Repeats specific sounds, words, phrases, or music frequently (e.g., repeats parts of movies or phrases from books)

33

Becomes upset easily with interruption to routines or unanticipated changes in events (e.g., taking a different route to a destination, moving a familiar object from “its place,” using a different color plate for meals

34

Other:

35

Has current speech delay (e.g., no sounds of content, vowel-like sounds between 2-3 months; no babbling at 8 months; no single words by 12 months; no phrase speech by 24 months)

36

Atypically quiet; does not produce a variety of sounds other than crying (e.g., cooing)

37

Displays absence of a social smile or displays a “vacant” smile

38

Does not imitate sound produced by a caregiver

39

Does not use varied voice intonation to express joy and pleasure

40

Does not respond or shows delayed response when name is called

41

Does not use turn-taking when vocalizing/verbalizing with a partner that includes a comfortable to-and-fro

42

Has difficulty using basic gestures, facial expressions of “body language” to communicate feelings

43

Fails to respond to verbal greetings or nonverbal gestures (e.g., wave bye-bye, raise arms to be picked up)

44

Has difficulty or makes no attempt to make clear requests (e.g., does not lift arms to be picked up, only labels objects-does not request by name)

45

Has difficulty understanding labels or names for common objects/people (e.g., does not point to picture in book upon request)

46

Has difficulty following a variety of routine one-step directions

47

Demonstrates unusual voice or speech qualities (e.g., hums, grunts; uses “sing-song” or mechanical speech

48

Fails to respond to verbal or nonverbal greetings by giving a verbal response (e.g., by saying “hi” or “bye”)

49

Communicates wants and needs through tantrums that appear more extreme in frequency and/or intensity than those of other children of the same age

50

Makes sounds or states the same words or phrases repeatedly

51

Talks to self excessively in place of communicating with others

52

Frequently uses “gibberish” with few recognizable words

53

Does not spontaneously comment or share experiences-may speak only when asked a direct question

54

Has difficulty with basic rules of conversation (e.g., asks inappropriate questions, makes poor eye contact, has difficulty maintaining conversation, wants to talk about own interests exclusively)

55

Displays immediate or delayed echolalia (e.g., repeats another person’s questions or statements, recites lines from a favorite book or movie repeatedly)

56

Uses words in odd or idiosyncratic manner (e.g., calling yellow objects “cheesy”)

57

Asks repetitive questions

58

Makes frequent mistakes in use of pronouns (e.g., reverses you and me or refers to self by name)

59

Notes on your particular student (you will complete this section if the item is applicable to your student)

60

Often responds in a developmentally unusual manner to sounds (e.g., reacts as if has no hearing, ignores some sounds, turns up volume on tv, bangs toys and objects, or overreacts to noises such as crowds or sirens)

61

Often responds in a developmentally unusual manner to pain (e.g., overreacts or seems unaware of an illness or injury)

62

Often responds in a developmentally unusual manner to temperature (e.g., prefers or avoids certain temperatures or fails to respond to temperatures)

63

Often responds in a developmentally unusual manner to smells (e.g., may comment on smells that others do not notice or fails to notice strong smells)

64

Often shows an unusually strong desire to do activities that provide touch or pressure (e.g., tight swaddling; crashing body into bed, sofa, or people; banging toys together)

65

Often shows an unusually strong desire to do activities that provide movement (e.g., swinging, rocking, spinning body, running; or being rocked or bounced by others)

66

Often shows an extreme overreaction to activities that provide touch or pressure (e.g., resists diaper changes, strongly dislikes hair washing or cutting, nail cutting, and/or tooth brushing; avoids touching foods or walking on grass)

67

Often shows an extreme overreaction to activities that provide movement (e.g., avoids swinging, climbing, rocking, or pacing)

68

Often responds in a developmentally unusual manner to visual input (e.g., focuses on shiny items and reflections; ignores faces; shows preference for or strong dislike of certain colors; overreliance on salient visual features such as glasses and hair)

69

Has had difficulty learning feeding skills and/or transitioning to more advanced feeding skills (e.g., from breast/bottle feeding to spoon feeding with smooth, thin purees and then to mixed textures)

70

Often responds in a developmentally unusual/rigid manner to taste (e.g., avoids many textures, foods, and flavors)

71

Frequently preoccupied with sensory exploration of objects (e.g., mouths, licks, chews, sniffs, holds close to eyes, rubs, squeezes, or uses object to make sounds)

72

Frequently makes noises such as humming, singing, or throat-clearing vocalizations

73

74

Takes longer to learn new skills or learns some skills much earlier than same-age peers (e.g., may be able to identify letters or numbers or read words at unusually young age)

75

Does not generalize learned skills to new settings or demonstrate them consistently upon request

76

Demonstrates inconsistent recall of information or routines (e.g., seems to forget what was previously learned)

77

Has difficulty engaging in adult-initiated activities

78

Has difficulty maintaining engagement in meaningful self-directed activities (e.g., persists with activities but only within preferred interests or remains engaged only in areas of restricted interests)

79

Recites, signs, lists, or labels with limited purpose or understanding (e.g., displays excellent memory for songs or stories)

80

Has difficulty following new or unfamiliar directions

81

Displays little or no pretend and imaginative play-only uses objects for intended purpose (e.g., banana as food not telephone)

82

83

Demonstrates awkward motor movements (e.g., head flops backwards when placed into sitting position, crawls, walks or runs atypically age, walks on toes)

84

Displays atypical activity level (e.g., overactive/hyperactive, underactive/very passive, or unusual stamina)

85

Displays variability in gross-motor skills (e.g., able to engage in some age-appropriate physical activities but not others, may climb furniture but seeks support climbing stairs)

86

Has difficulty maintaining hold or actively resists grasping objects or a tool (e.g., chalk, crayon, marker, pencil, paintbrush for purposeful activities)

87

Displays unusual facial expressions or grimacing

88

Has extreme difficulty starting or stopping actions (e.g., difficulty feeding self, moving through environment, or playing with objects)

89

Has difficulty independently moving through environment and appropriately maneuvering around objects and people (e.g., difficulty crawling, moving room to room, walking on uneven surfaces, moving on/off a chair)

90

Has difficulty using hands for fine-motor tasks (e.g., holding a crayon, using eating utensils, turning a single page, fastening, buttoning, and zipping)

91

Displays variability in fine-motor skills (e.g., can accomplish some tasks, but not others, may use one hand in a very precise manner to manipulate small objects, but does not use hands together for combined stabilizing and skill)

92

Displays unusual or repetitive body postures and movements (e.g., hand flapping, rocking, finger flicking, moving fingers in front of face, and spinning)

93

94

Exhibits more extreme emotional responses, in duration and/or intensity, than other children of the same age

95

Demonstrates unusual fear response-lacks appropriate fears or is overly fearful

96

Emotional responses are not related to the situation (e.g., laughs for no apparent reason)

97

Displays great difficulty being comforted by parents/caregivers when upset-is not easily calmed

98

Has more difficulty expressing and/or controlling emotions than other same-age children

99

Does not find pleasure in activities and interactions similar to children the same age; seems withdrawn

100

Appears to purposefully injure self (e.g., bangs head, picks skin, bites nails until finger bleeds, bites self)

101

Becomes stressed when presented with a new task or situation (e.g., does not initially attempt new things)

102

Shows persistent aggressive behaviors with people and/or objects that do not readily respond to typical developmental interventions (e.g., persistently harms others or breaks objects)

103

Has low frustration tolerance

104

Item

Description

Notes/examples on your particular student (you will complete this section if the item is applicable to your student)

Intervention (describe one specific thing you would do to address this need)

1

Has difficulty recognizing the feelings and thoughts of others (mindblindness)

2

Uses poor eye contact or fails to orient to others

3

Shows little interest or response to praise

4

Does not seek others’ attention in order to share an experience (e.g. bring an object to show, point out an item or person)

5

Interacts with others as if they were objects (e.g. cause and effect)

6

Has difficulty maintaining personal space, physically intrudes on others

7

Has difficulty taking turns in social interactions or activities

8

Has difficulty imitating the actions or words of others

9

Fails to respond to the eye gaze or pointing of others—does not orient to the object or person

10

Has difficulty making or keeping friends

11

Has difficulty joining an activity

12

Is naïve, easily taken advantage of, or bullied

13

Has difficulty waiting

14

Chooses or prefers solitary activities

15

Has difficulty understanding non-verbal communication (e.g. tone of voice, facial expressions, body language)

16

Appears to be unresponsive to others (e.g. unaware of presence of others; ignores greetings, questions, and requests)

17.

Shows little curiosity or interest in others or the immediate environment—appears to be in “own world”

18.

Other: Describe

19

Expresses strong need for routine or “sameness”—has difficulty with change

20

Displays rituals/non-functional routines (e.g. must perform activities in an unusual and specific way)

21.

Uses objects in repetitive, atypical manner (e.g. meticulously lines up objects, purposefully drops objects to see them fall)

22

Seeks repetition of specific sounds, words, phrases, or music

23

Has distinct preference for objects that move

24

Has eccentric or intense preoccupations—absorbed in own unique interests

25

Attached to unusual objects

26

Seems to be unmotivated by customary rewards (e.g. stickers, social praise)

27

Displays repetitive motor movements (e.g. flaps hands, paces, rocks)

28

Has difficulty transitioning from a preferred activity

29

Has strong need for closure or difficulty stopping a task before it is completed

30

Displays difficulty engaging in activities other than intense special interests

31

Other : Describe

32

Has little or no speech

33

Has difficulty expressing wants and needs

34

Makes frequent mistakes using pronouns (e.g. reverses he and she)

35

Makes sounds or states words or phrases repeatedly

36

Does not respond or shows delayed response when name is called

37

Makes up new words or creates alternate meanings for words or phrases

38

Displays immediate or delayed echolalia (e.g. recites lines from movies, repeats another person’s questions or statements, repeats sounds)

39

Asks repetitive questions

40

Talks to self excessively

41

Interprets words or conversations literally—has difficulty understanding figurative language

42

Has difficulty with rules of conversation (e.g. interrupts others, asks inappropriate questions, makes poor eye contact, has difficulty maintaining conversation, staying on topic)

43

Fails to initiate or respond to greetings

44

Communicates needs through behaviors such as crying, aggression, destruction of property

45

Has difficulty using gestures and facial expressions or makes unusual facial expressions

46

Has difficulty staring, joining, and/or ending a conversation

47

Has difficulty asking for help

48

Does not respond to comments—may speak only when asked a direct question

49

Has difficulty expressing thoughts and feelings

50

Displays absence of smile or “vacant” smile

51

Has unusual voice or speech qualities (e.g. babbles, hums, grunts; uses “sing-song” or mechanical speech)

52

Has difficulty following instructions

53

Has difficulty understanding language with multiple meanings, humor, sarcasm, or synonyms

54

Displays little pretend or imaginative play or thought

55

Notes on your particular student (you will complete this section if the item is applicable to your student)

56

Responds in an unusual manner to sounds (e.g. ignores sounds or overreacts to sudden, unexpected noises, high-pitched continuous sounds, or complex/multiple noises)

57

Responds in an unusual manner to pain (e.g. overreacts or seems unaware of illness or injury)

58

Responds in an unusual manner to taste (e.g. resists certain textures, flavors, brands)

59

Responds in an unusual manner to light or color (e.g. focuses on shiny items, shadows, reflections, shows preference or strong dislike for certain colors)

60

Responds in an unusual manner to temperature

61

Responds in an unusual manner to smells (e.g. may comment on smells that others do not detect)

62

Seeks activities that provide touch or pressure, or movement (e.g swinging, hugging, pacing)

63

Seeks activities that provide movement (e.g swinging, rocking, spinning, pacing)

64

Avoids activities that provide touch, pressure (e.g. resists wearing certain types of clothing, strongly dislikes to be dirty, resists hugs)

65

Avoids activities that provide movement (e.g. running, sports)

66

Preoccupied with sensory exploration of objects (e.g. mouths, licks, chews, sniffs, holds close to eyes, rubs, squeezes, or uses objects to make sounds)

67

Makes noises such as humming or singing frequently

68

69

Has below-average or severely delayed intellectual abilities

70

Has excellent memory for details (e.g. facts, stories, movies, songs)

71

Demonstrates learned skills erratically/inconsistently (i.e. may not demonstrate skill upon request)

72

Displays weaknesses in reading comprehension but has strong word recognition

73

Has difficulty applying learned skills in new settings

74

Demonstrates academic skills deficits

75

Has attention problems

76

Has difficulty organizing self in order to initiate or complete an activity

77

Displays very literal understanding of concepts

78

Recalls information inconsistently (i.e. seems to forget previously learned information)

79

Has difficulty understanding the connection between behavior and resulting consequences

80

81

Has difficulty with handwriting

82

Has atypical or weak grasp

83

Has poor motor coordination or is accident prone

84

Has difficulty using hands for fine-motor tasks (e.g. fastening, buttoning, zipping, tying shoes, using eating utensils)

85

Displays atypical activity level (e.g. over-active/hyperactive, under-active/hypoactive)

86

Has difficulty moving through environment (e.g. in and out of buildings, using stairs, walking on uneven surfaces)

87

Has athletic skills deficits

88

Displays an awkward gait

89

Displays unusual body postures and movements or facial expressions (e.g. odd postures, stiffness, “freezing, facial grimacing)

90

Has difficulty starting or completing actions (e.g. may rely on physical or verbal prompting by others)

91

92

Is anxious or easily stressed

93

Appears to be depressed or sad

94

Becomes stressed when presented with new task or novel situation (e.g. does not initially attempt new things)

95

Has unusual fear responses—lacks appropriate fears or is overly fearful

96

Exhibits rage reactions or “meltdowns” in response to apparently minor events

97

Injures self (e.g. bangs head, picks skin, bites nails until they bleed, bites self)

98

Displays inconsistent behaviors

99

Has difficulty tolerating mistakes—own and others’

100

Has low frustration tolerance

101

Has difficulty identifying, quantifying, expressing and/or controlling emotions (e.g. can only recognize and express emotions in extremes or fails to express emotions—“emotionally “flat”)

102

Has a limited understanding of own and others’ emotional responses

103