Case ID Number:Name of person to be rated:(Required)Date of birth of person to be rated:(Required) MM slash DD slash YYYY Gender of person to be rated:(Required)selectMaleFemaleYour name:(Required) First Last Your relationship to the person to be rated:InstructionsThis form asks about behaviors in several areas where people may have difficulty. The person you are rating may or may not have ever shown these behaviors. For each behavior listed, please make a check mark under the description that best describes the person you are rating. Check the box under Don't Know if you do not have enough information about a behavior to give a rating. It is important to provide an answer for every behavior. After each section, there is space for you to give one or more brief, specific examples that relate to your ratings in that section. Use the blank page at the end of the form if you need extra space. The final section of this questionnaire provides spaces where you can describe any other behaviors that you would like us to know about.Section 1 - How does the person you are rating communicate?1.1 - Imitates sounds, words, and movements of othersNot a Problem (Does very well)Mild-to-Moderate Problem (Sometimes a problem)Severe Problem (Often or always a problem)Not a problem now, but was in the pastDon’t Know1.2 - Responds to facial expressions, gestures, and different tones of voice used by othersNot a Problem (Does very well)Mild-to-Moderate Problem (Sometimes a problem)Severe Problem (Often or always a problem)Not a problem now, but was in the pastDon’t Know1.3 - Responds to his or her name being called by turning and making eye contact with the person calling his or her nameNot a Problem (Does very well)Mild-to-Moderate Problem (Sometimes a problem)Severe Problem (Often or always a problem)Not a problem now, but was in the pastDon’t Know1.4 - Directs facial expressions to others to show the emotions he or she is feelingNot a Problem (Does very well)Mild-to-Moderate Problem (Sometimes a problem)Severe Problem (Often or always a problem)Not a problem now, but was in the pastDon’t Know1.5 - Uses a variety of gestures (pointing, nodding the head, showing the size of something) that are coordinated with words or used to explain things when he or she doesn't have the words to do soNot a Problem (Does very well)Mild-to-Moderate Problem (Sometimes a problem)Severe Problem (Often or always a problem)Not a problem now, but was in the pastDon’t KnowIs the person you are rating using words?(Required) Yes No 1.6 - Uses made-up words or repeats specific words or phrasesNot a Problem (Does very well)Mild-to-Moderate Problem (Sometimes a problem)Severe Problem (Often or always a problem)Not a problem now, but was in the pastDon’t Know1.7 - Has an unusual tone, rhythm, loudness, or rate of speechNot a Problem (Does very well)Mild-to-Moderate Problem (Sometimes a problem)Severe Problem (Often or always a problem)Not a problem now, but was in the pastDon’t Know1.8 - Speech is overly formal; for example, uses vocabulary that seems more sophisticated than usual for a person of his or her age or for the situationNot a Problem (Does very well)Mild-to-Moderate Problem (Sometimes a problem)Severe Problem (Often or always a problem)Not a problem now, but was in the pastDon’t Know1.9 - Carries on a conversation with another person that flows back and forth, at a level you would expect for someone of his or her ageNot a Problem (Does very well)Mild-to-Moderate Problem (Sometimes a problem)Severe Problem (Often or always a problem)Not a problem now, but was in the pastDon’t Know1.10 - Can talk with another person about that person's interestsNot a Problem (Does very well)Mild-to-Moderate Problem (Sometimes a problem)Severe Problem (Often or always a problem)Not a problem now, but was in the pastDon’t KnowSection 1 Examples - Give one or more brief but specific examples of the problem behaviors rated above.Section 2 - How does the person you are rating relate to others and show emotion?2.1 - Makes eye contact when speaking with or listening to another personNot a Problem (Does very well)Mild-to-Moderate Problem (Sometimes a problem)Severe Problem (Often or always a problem)Not a problem now, but was in the pastDon’t Know2.2 - Points to and shares things of interest with othersNot a Problem (Does very well)Mild-to-Moderate Problem (Sometimes a problem)Severe Problem (Often or always a problem)Not a problem now, but was in the pastDon’t Know2.3 - Follows another person's gaze or points toward an object that is out of reachNot a Problem (Does very well)Mild-to-Moderate Problem (Sometimes a problem)Severe Problem (Often or always a problem)Not a problem now, but was in the pastDon’t Know2.4 - Is responsive to social initiations from othersNot a Problem (Does very well)Mild-to-Moderate Problem (Sometimes a problem)Severe Problem (Often or always a problem)Not a problem now, but was in the pastDon’t Know2.5 - Initiates social interactions with adults and peers (not just to get a basic need met)Not a Problem (Does very well)Mild-to-Moderate Problem (Sometimes a problem)Severe Problem (Often or always a problem)Not a problem now, but was in the pastDon’t Know2.6 -Sustains an interaction with others in an easy, flowing, back-and-forth mannerNot a Problem (Does very well)Mild-to-Moderate Problem (Sometimes a problem)Severe Problem (Often or always a problem)Not a problem now, but was in the pastDon’t Know2.7 - Makes and maintains friendships with peers of same developmental levelNot a Problem (Does very well)Mild-to-Moderate Problem (Sometimes a problem)Severe Problem (Often or always a problem)Not a problem now, but was in the pastDon’t Know2.8 - Shows a range of emotional expressions that match the situation (for example, smiles, frowns, conveys different emotions through eyes and facial expressions, etc.)Not a Problem (Does very well)Mild-to-Moderate Problem (Sometimes a problem)Severe Problem (Often or always a problem)Not a problem now, but was in the pastDon’t Know2.9 - Understands and responds to how another person may be thinking or feeling (for example, tries to comfort someone in distress, does something because he or she thinks the other person will like it)Not a Problem (Does very well)Mild-to-Moderate Problem (Sometimes a problem)Severe Problem (Often or always a problem)Not a problem now, but was in the pastDon’t KnowSection 2 Examples: Give one or more brief but specific examples of the problem behaviors rated above.Section 3 - How does the person you are rating move his or her body?3.1 - Has unusual ways of moving fingers, hands, arms, legs; or spins or rocks bodyNot a Problem (Does very well)Mild-to-Moderate Problem (Sometimes a problem)Severe Problem (Often or always a problem)Not a problem now, but was in the pastDon’t Know3.2 - Does things that might result in self-injury, like scratching, head banging, picking at his or her skinNot a Problem (Does very well)Mild-to-Moderate Problem (Sometimes a problem)Severe Problem (Often or always a problem)Not a problem now, but was in the pastDon’t Know3.3 - Is clumsy, stumbles, or has an awkward walk or runNot a Problem (Does very well)Mild-to-Moderate Problem (Sometimes a problem)Severe Problem (Often or always a problem)Not a problem now, but was in the pastDon’t Know3.4 - For school-aged children or adults: Has difficulty tying shoes or difficulty with handwriting or other tasks that require fine motor coordinationNot a Problem (Does very well)Mild-to-Moderate Problem (Sometimes a problem)Severe Problem (Often or always a problem)Not a problem now, but was in the pastDon’t KnowSection 4 - How does the person you are rating play? (For an older individual, how did he or she play as a child?)4.1 -Uses only parts of toys instead of whole toys, or plays with objects (e.g., opens and closes toy barn doors, spins wheels on cars, wobbles or spins household objects)Not a Problem (Does very well)Mild-to-Moderate Problem (Sometimes a problem)Severe Problem (Often or always a problem)Not a problem now, but was in the pastDon’t Know4.2 - Plays with the same things in the same way over and overNot a Problem (Does very well)Mild-to-Moderate Problem (Sometimes a problem)Severe Problem (Often or always a problem)Not a problem now, but was in the pastDon’t Know4.3 - Uses toys or other materials to represent something they are not (e.g., uses a banana as a phone or a microphone)Not a Problem (Does very well)Mild-to-Moderate Problem (Sometimes a problem)Severe Problem (Often or always a problem)Not a problem now, but was in the pastDon’t Know4.4 - Engages in make-believe play, taking on a role (not based on scripts from movies or TV shows)Not a Problem (Does very well)Mild-to-Moderate Problem (Sometimes a problem)Severe Problem (Often or always a problem)Not a problem now, but was in the pastDon’t KnowSections 3 & 4 Examples: Give one or more brief but specific examples of the problem behaviors rated above.Section 5 - How does the person you are rating react to new experiences and changes in routine?5.1 - May show anxiety or worry in facial expression or body movement, or by becoming overly impatientNot a Problem (Does very well)Mild-to-Moderate Problem (Sometimes a problem)Severe Problem (Often or always a problem)Not a problem now, but was in the pastDon’t Know5.2 - May show worry about the same thing over and over againNot a Problem (Does very well)Mild-to-Moderate Problem (Sometimes a problem)Severe Problem (Often or always a problem)Not a problem now, but was in the pastDon’t Know5.3 - Copes with changes in routine or the environment (for example, moving furniture)Not a Problem (Does very well)Mild-to-Moderate Problem (Sometimes a problem)Severe Problem (Often or always a problem)Not a problem now, but was in the pastDon’t Know5.4 - Has specific routines or specific ways things must be done by self or othersNot a Problem (Does very well)Mild-to-Moderate Problem (Sometimes a problem)Severe Problem (Often or always a problem)Not a problem now, but was in the pastDon’t Know5.5 - Has special interests or topics (for example, dinosaurs, trains, clocks, weather, license plates)Not a Problem (Does very well)Mild-to-Moderate Problem (Sometimes a problem)Severe Problem (Often or always a problem)Not a problem now, but was in the pastDon’t KnowSection 6 - How does the person you are rating use his or her senses of vision, hearing, touch, and smell?6.1 - Tends to look at objects from unusual angles or out of the corner of his or her eyesNot a Problem (Does very well)Mild-to-Moderate Problem (Sometimes a problem)Severe Problem (Often or always a problem)Not a problem now, but was in the pastDon’t Know6.2 - Is overly interested in light from mirrors or light reflecting off objectsNot a Problem (Does very well)Mild-to-Moderate Problem (Sometimes a problem)Severe Problem (Often or always a problem)Not a problem now, but was in the pastDon’t Know6.3 - Is overly sensitive to some sounds, smells, or textures; seeks some out, actively avoids othersNot a Problem (Does very well)Mild-to-Moderate Problem (Sometimes a problem)Severe Problem (Often or always a problem)Not a problem now, but was in the pastDon’t Know6.4 - Has an unusual response to touch; may overreact to touch or pain or may not respond to things that others would find uncomfortable or painfulNot a Problem (Does very well)Mild-to-Moderate Problem (Sometimes a problem)Severe Problem (Often or always a problem)Not a problem now, but was in the pastDon’t KnowSections 5 & 6 Examples: Give one or more brief but specific examples of the problem behaviors rated above. If you need more space to write, use the blank page at the end of this form.Section 7 - Other Behaviors7.1 - Does this individual have any extremely unusual mathematical, reading, or artistic abilities? No Yes 7.1a - Please explain7.2 - Are there other unusual behaviors you have noticed that you would like to tell us about? Yes No 7.2a - Additional Behavior Examples or Comments:BehaviorNumber of related question from above Add RemoveClick/touch the icon to add additional Examples/Comments