Child’s Name: _______________ Observer: _______________ Date: _____________
Social Behaviors (1=not very true, 5=very true)
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A. Fails to initiate interactions with adults |
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B. Fails to initiate interactions with peers |
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C. Fails to respond to initiations from adults |
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D. Fails to respond to initiations from peers |
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E. Fails to use eye contact during interactions |
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Communication (1=not very true, 5=very true)
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A. Fails to communicate to request |
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B. Fails to communicate to direct attention |
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C. Fails to use nonverbal gestures |
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D. Fails to use speech to communication |
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E. Shows unusual speech/language characteristics |
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Restricted Activities/Interests
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A. Fails to engage in imaginative play |
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B. Engages in repetitive play activities |
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C. Engages in repetitive motor behaviors |
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D. Responds inconsistently to sounds |
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E. Shows unusual visual interests |
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