Section 1. Identifying Information ame Braminer’s Name Female [1] Male 1] Examiners Tile Year Month Day Parent/Guardian Date Tested SchoolDay Care Date of Birth Respondent’ Name Age Relationship to Child ‘Age in Months Gag) Length of Time Respondent Has Known Child Section 2. Record of Scores Raw ‘Age ile Standard Score Equivalent Rank Score SEM Descriptive Term ace 3 Section 3. Descriptive Terms DescriptiveTerm Very Poor Poor Below Average Average Above Average Super ‘VerySuperir Standard <7 20-79 80-89 11-120 121-130 > 20 Section 4. Observations and Recommendations (©2013 by PROD, In 789 0 Now ww oT ‘Addo oie o ths frm #13747 my bps rom PROD 8700 Shoal ek Bl, Austin TY 757-4857 85-320, Fa 80/397-7633, weroedccom_Seetion5, Record of Performance Adaptive Behavior Domain Instructions: Basal and ceil starting points are determined by the childs age, Score 1 ifthe child does exhibit she behavior described most of Nee ror aid when he or she was younger but has outgrown the behavior. Score Of the child eloes not exhibit the behavior described or exhibits the behavior inconsistently Begin atthe starting point. Administer items until three consecutive items receive 9 Sot of 0 (Le, to establish a telingy ifthe child receives a score of on any ofthe fist three items, test backward until the child scores a 1 on caaa ms ia row (ve, to establish a basal). the chill doesnot receive a score of 0 on three consecttht At ie establishing a basal, return to highest iter number scored and continue testing untl a celing fs established, Birth-11 months: Item 1 24-35 months: Item 23 48-59 months: tem 44 Entry Points: 12-23 months: Item 14 36-47 months:Item34__60 months and older Item 50 Item | Score # | (lord) tem oe a ae oe * maintains body temperature without external assistance 2 “forms a tight seal around nipple when sucking un. 2 3. “a, 1s, 16. 17. 18, _ swallows liquids with no difficulty coordinates sucking, swallowing, and breathing _ opens mouth naspaton feeding lah oben or bate enjoys bath keeps eyes open and indicates pleasure when placed in warm water | sleeps for 4- to 10-hour intervals, closes lips when swallowing swallows pureed foods Uses tongue to move food around in mouth | grows definite likes and dislikes of various foods (e<, may spit out or refuse to. open IPs for undesired foods, eagerly opens mouth for desired foods) | Jeeps through the night: may take two to three naps during the day | holds or supports a bottle to feed self | purposely pulls off own socks “feeds self finger foods _ chews textured foods ‘cooperates in dressing and undressing (e, helps put arms in holes) “leeps through the night: may take one nap during the day drinks from open cup or glass held by adult (not a sippy cup)*Entry Points: _Birth-11 months: Item 1 24-35 months: Item 23, 48-59 months: Item 44 12-23 months: Item 14 36-47 months: Item 34 (60 months and older: tem 50 Item | Score # | (oro) tem 20. | sips liquid from glass or cup using a straw a helps with simple household task eg, helps put things away) 22, fusses when diaper needs tobe changed "23, tries to wash own hands and face 24, "removes loos clothing sch eck shots ora shirt without sstnce . 25. opens door by using handle or knob : 26. puts on simple clothing independently (e.g., hat, pants) 27. independently eats entire meal with spoon isis 28, wipes own nse;may need to be reminded 29, sts on ot for atleast 1 minute supervised 30. squats, holds efor verblzes bowel and bladder needs mostof te time a washes and dies hands and face without assistance i 22, cleans upspis getting own cloth 2 shows care when hanling an infant or smal animal "34 pours mikorjucewihsomeassstance ion 35, tells adult of toilet needs in time to eto tlt 36 takes espns fr toting: nay requ asstance in wiping ¥. dik of water om tap unas ay need hep geting cup fom cupboard) a 38 brushes teeth independently 38. recognizes own home 40. "manipulates large buttons o snaps 4. covers mouth and nose when coughing an sneezing than elbow, sue orhandkarchie may be used) 42. seep though the ight without wetting 43 hangs up dothes (hanger hook, or other designated device) =i dresses self completely except for ying shoelaces (includes underwear clothes must be on corti including alfasteners) 45, serves slfat the table adult may need to hold serving dish) 46 often wants privacy in bathom“Entry Points: —Birth-11 ‘months: Item 1 24-35 months; Item 23 48-59 months: Item 44 Se mente ae aTmontatamst__S rasa der se team | Score se) em 4. answers what-to-do-if question (g."What would you do fyou cutyour finger”) 48. fastens seat belt in automobile independently 49. crosses street safely 2g, looks both ways, uses crosswalks) *50. puts dirty dishes in sink or dishwasher 51 requests food to be passed at the table 52. selects clothing appropriate for temperature and occasion 53. makes ov bed: may need to be reminded 54. sets and clears table without assistance 55, ses table knife for spreading soft butter, jelly, or peanut butter 56. plans ahead to meet tlleting needs before beginning an activity 97. takes shower or bath independently 58, cleans counter or work surface with sponge or paper towels 59, dusts furniture 60. sakes simple breakfast and lunch 61 washes own hair 62. takes care of minor cuts (cleans and applies bandage) 6. rides a bicycle safely without training wheels 64. cuts food {including meat) into bite-sized pleces (_) omnes