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by Millie Smith and Stacy Shafer

Student's Name: Catherine
Date of Assessment: 3/5/95

Name(s) of Assessor(s): M. Smith, P. Castro (mother), N. Jones

Assessment Period
School day starts at: 8:15 a.m
School Day ends at: 3:30 p.m.

Nonschool environments:
Place: Home From: 4:00 p.m. To: 8:30 p.m.
Place:           From:                   To:

The total assessment period should be at least one school day. Assessment of the student in nonschool environments on the same day would be extremely helpful.

Recording Schedule

Indicate the length of the interval between recordings in Part II. Intervals should be no shorter than one minute and no longer than 15 minutes. The intervals should be consistent throughout the assessment period. Part II information will be recorded every 15 minutes.

Part I

Provide the information called for in the grids for the 24 hours preceding the beginning of the assessment and throughout the assessment period. Under "Comment" indicate any significant factor that comes to mind and be sure to note when the recorded information is a departure from the student's typical routine. If there are significant departures or if the student is ill on the day of assessment, postpone the assessment.

Note: This is an informal teacher-made assessment based on the Carolina Record of Individual Behavior (CRIB), by R. J. Simeonsson et al. and the Project ABLE Manual: Analyzing Behavior State and Learning Environments Profile by B. Guy et al.

Food and Liquid Information

Each time the student eats something, drinks something, or is tube fed, enter the following information on the grid:
(the table has five columns titled Type, Start Time, Stop Time, Amount, and Comment)

Food and Liquid Information
TypeTime StartTime StopAmountComment
Ensure. 8:20 8:40 16 oz  
Water. 8:40 8:45 6 oz  
Ensure 12:30 1:20 16 oz.  
Water 1:10 1:15 6 oz.  
Ensure 4:30 4:50 16 oz.  
Water 4:50 5:00 6 oz.  
Ensure 8:00 8:20 16 oz.  
Water. 8:20 8:25 6 oz  

Medication Information

Each time the student takes a prescription or over the counter medication enter the following information on the grid:

Medication Information
Tegretol Suspension 8:20 a.m. 200 mg  
Dimetap Elixir 8:20 a.m. 10 cc for congestion
Dimetap Elixir 12:30 p.m. 10 cc  
Tegretol Suspension 4:30 p.m. 200 mg  
Dimetap Elixir 4:30 p.m. 10 cc  

Seizure Information

Each time a seizure occurs, enter the following information on the grid:

Medication Information
Start Time Stop TimeDescriptionComment
    none observed  

Sleep Information

Each time the student sleeps for more than five minutes, enter the following information on the grid. If the student's sleep is interrupted for longer than three minutes, enter a stop time and begin a new sleep episode on the next line:

Sleep Information
Start TimeStop TimeLocationComments
9:00 p.m. 12:00 p.m. Bedroom Cried to request in bed change in position
12:15 p.m. 3:20 p.m. " "
3:28 p.m. 6:15 p.m.. " Playing quietly in bed when checked at 6:15

Part II - Instructions

Time: Record the clock time for every third interval recorded. This will help show the continuity of the assessment.

State: Record the state at the moment of observation, not the prevalent state for the entire interval.

Position: Indicate the position the student is in at the moment of observation (e.g., sitting, side-lying, prone, supine, standing).

Specific External Stimuli Available: Describe the specific external stimuli available to the student at the moment of observation (e.g., music, vibrator, swing, water, food, Little Room, mobile). If no material is available, enter a zero.

Ambient Conditions: Describe the characteristics of the surrounding (e.g., room temperature, noise level, conspicuous smells, lighting) for the first state recorded and whenever conditions change. When no change occurs, put ditto marks in the column.

Social Conditions: Record the name of the person interacting with the student at the moment of observation. The person must be talking to the student, touching the student, and/or co-actively manipulating an object with the student. The passive presence of another person should not be recorded. If no person is interacting with the student, enter zero.

Key to Part II Assessment

State Key: _ = Seizure; S = Sleep; D = Drowsiness; QA = Quiet Awake; AA = Active Awake; FA = Fussy Awake; MA = Mild Agitation; UA = Uncontrollable Agitation.

TimeActivityStatePosition Spec. Ext. Stimuli Avai.lAmbient ConditionsSocial Conditions
8:15 Arrival QA Seated 0 Outdoors cold, windy, noisy chairlift in bus Greeted by TA  Linda
8:30 Breakfast D Supine 0 Normal temperature and lighting 0
8:45 Tooth-brushing MA Seated Toothbrush, toothpaste, water, towel Noisy bathroom,very bright lighting Hand-over-hand   manipulation; L
9:00 Hair Drying QA Seated Hairdryer, mousse, brush Normal temperature and lighting Talking; Linda
9:15 Hair Brushing QA Seated Hairdryer, mousse, brush Normal temperature and lighting Talking; Linda
9:30 Drama Class AA Seated Papier mache material Dark stage area, echoes Surrounded by peers
10:00 Changing AA Supine Cold wipes, talcum  powder Normal temperature  and lighting Patting, talking; Linda
10:15 Mail Delivery AA Rolling  prone stander Variety visual & auditory stimuli avail. Many changes; different noise levels Interaction with 6 different adults
        Remainder of day not shown    

Part III - Summary

Typical duration of alert states: 15 to 20 minutes

(Note: If the student is typically alert less than one minute, a different type of biobehavioral assessment will be necessary. Consider assessing one activity at 30 second intervals. The purpose of this assessment would be to try to determine what influences cause state changes and to provide modifications associated with changes to more alert states.)

Positions during alert states: Seated, standing (in prone stander)

Specific external stimuli available during alert states: Movement; tactual materials (e.g., paper, hairbrush); auditory, especially human voice

Ambient conditions during alert states: Normal lighting, temperature, low noise level

Social conditions during alert states: Talking and touching

Less than alert states typically occurred when: There was no social interaction

Agitated states typically occurred when: There was too much noise or strong smells and just before feeding

If you have concerns about food and liquid intake or medications, talk with parents and other team members about getting more information.

Do you have concerns about food and liquid intake being adequate for maintenance of alert states:

___X__ Yes  ______ No

Do you have concerns about medication and/or medication schedules facilitating alert states at optimum programming times:

___X___Yes   _____  No