Teacher’s Name (optional):  ______________

1.  How many children are in your classroom?

2.  What is the age range of the children in your classroom?

3.  How many children in your classroom have a diagnosis of Autism or PDDNOS?

4.  How many children in your classroom could serve as peer models for socialization?

5.  For the children with autism:

                a.  What characteristics do these children appear to have in common?


                b.  How are these children different from one another?


6.  Please list the daily schedule of activities in your classroom:



























7.  How do you indicate to the children when it is time to change activities?

8.  Given this list of activities:

                a.  Which activities appear to be more difficult for the children with autism?


                b.  During which activities are behavior problems most likely to occur?


                c.  Which activities appear to be more enjoyable for the children with autism?


                d.  During which activities do the children with autism show more appropriate behaviors?


9.  What would you like to gain from participating in this workshop?


10.  Are there any specific behavior problems exhibited by your students with autism that you would like help with?  If so, please complete the following section:


a.  How old is the child with the presenting behavior problem?


b.  Does this child have a functional way of communicating what he/she wants?

                If so, what mode of communication does he/she use most:

                                ___  words

                                ___  sign language

                                ___  gestures

                                ___  pictures or symbols

                                ___  other (please describe)


c.  Please describe the problem behavior  (i.e., what does it look like):


d.  Are there specific situations where this behavior is more likely to occur?  (e.g., during free play, during difficult tasks, when it is time to change activities, etc.)


e.  On average, how many times per day does the child show this behavior?


f.  How do you respond to this behavior from this child?


g.  What other strategies have you tried in the past?


h.  Why do you think the child behaves in this way?



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