ࡱ>  5+bjbjMFMF (/,/,"Lxx99999MMMM8DM,>,@,@,@,@,@,@,Q-/@,9@,99U,*99>,>,R99v8Mj k,0,r,{0{09x :   REINFORCEMENT ASSESSMENT FORM Students Name:______________________ Completed By:_____________________ Date:________________ Prior to beginning the pairing process, it is important to identify ALL of your students motivators or reinforcers. Many students have very specific reinforcers and may engage with them in certain ways. Please provide as much detail as possible. Please indicate your students preferences below. Please provide specifics if possible (e.g., what kind, brand, type, etc.). Cross off (X) if student hates. What are your students preferences (likes and dislikes)? Puzzles: Games: Musical Instruments: Play Dough:Action Figures:Notes: Other:  Sensory Preferences: (be sure to include likes AND dislikes) Auditory (sounds): Visual (light, colors): Tactile (contact, textures): Kinesthetic (movement): Olfactory (smells): Gustatory (tastes):  What are your students entertainment preferences? Movies: TV:Animation/Cartoons:Music: Video Games:Board Games/Other:List some of your students favorite videos/tv shows/performers: Circle (O) if student likes. Cross off (X) if student hates. Please provide specifics, if possible (e.g., what kind, brand, type, etc.) What activity does your student prefer when using the computer? CD ROM Games: Internet Sites: List your students favorite CD ROM Games: List your students favorite Internet Sites: Things Tokens Favorite Subjects Balloons Other toys: Certificates Art Blocks Puppets Check register Math Chalk/crayons Shiny/Sparkly Toys Grades Music Dress Up Materials Slinky Honor Roll Gym/PE Dolls/Figurines Spinning Toys Marbles/Chips Reading Funny Glasses Stickers Money Writing Jewelry Stopwatch Other: Spatial Koosh Balls Stuffed Animals Points/Numbers Science Lighted Toys Textured Balls Signatures Social Studies Liquid Timers Toy Cars Special badges Library Machines Trains Stars/smiley faces Foreign Language: Marbles Wind-up Toys Tickets Other: Noisy Cars/Vehicles Vehicles Sports Appearance Books (bk): Aerobics Skating Dressing Up Pop-Up Basketball Skiing Make-up Bks w/ Sound: Bike riding Soccer Manicures Puzzle bk Bowling Softball/baseball Massages Picture bk Fishing Swimming Perfume/cologne Sensory bk Football Tennis Picture taken Sticker bk Horseback riding Volleyball Other: Magazines Jumping rope Walking/jogging Coloring bk Other: Weight training Flip bk Circle (O) if student likes. Cross off (X) if student hates. Please provide specifics, if possible (e.g., what kind, brand, type, etc.) Activities Being cafeteria helper Go to office on an errand Sand play Being excused from homework Going to the beach Staying up late Being group leader Going to the store Science Being principals helper Helping librarian Sharing information Bicycling Helping the custodian Sharpening pencils Blowing pinwheels Indoor walk Singing Blowing/popping bubbles Leaving town Sitting on bouncy balls Building models Letters Sitting/laying down Chairing a meeting Line leader/monitor Sleeping late Coloring Listening to a story Social studies Cutting with scissors Listening to music Spelling Dancing Listening to stories Taking showers/baths Decorating (walls, room) Math Telling stories Demonstrating a hobby to the class Molding clay Time off from school Displaying work Numbers Unsupervised time Drawing Other: Using tools Drawing on chalkboard Outdoor walk Using trampoline Earning money Painting with brush Using treadmill Erasing chalkboards Participating in crafts Visiting library Extra or longer recess Pasting or gluing Visiting museums Finger painting Picnics Visiting parks Fixing a bulletin board Playing chase/running Visiting relatives Getting a badge to wear for day Playing games like Simon Says Watching videos Gluing Playing with balls Water play Going out to eat Playing with microphone Working on computers Going to concerts/shows Reading Writing Recess/free time Writing notes Riding in car Running errands Circle (O) if student likes. Cross off (X) if student hates. Please provide specifics, if possible (e.g., what kind, brand, type, etc.) What are your students outdoor activities? Bicycle:Swing Set:Trampoline: Theme Parks:Swimming:Slide: Other Notes:  What are your students preferences for pets? Cats:Dogs:Hamsters:Fish:Gerbils:Other Notes:  Circle (O) if student likes. Cross off (X) if student hates. Please provide specifics, if possible (e.g., what kind, brand, type, etc.) Getting a special certificate Group activities Silly faces Good note home Having a choice of seatmate Sleepovers High fives Having lunch with the teacher Smiles/gestures Animal sounds High volume praise Songs Being head of lunch line Hugs Spinning Bouncing Kidding and joking Squeezes Dancing Pats Talking on the phone Enthusiastic praise Phone call for good behavior Talking with friends Fast-paced tickles Playing with a friend Talking with teacher Gentle tickles Praise Time with parent Getting a happy face on paper Rough housing Tutoring other students Getting positive comments on homework Scratches Whispered praise Shoulder rubs Circle (O) if student likes. Cross off (X) if student hates. Please provide specifics, if possible (e.g., what kind, brand, type, etc.) What are your students favorite snacks/foods? Candy:Fruit: Cookies:Crackers: Chips:Pretzels: Ice Cream:Other: List your students favorite brand names:  What are your students favorite beverages? Soda:Juice:Water: Milk:List your students favorite flavors and brand names: Other:  Having a snack M & Ms Chocolate chips Raisinettes Skittles Sweet tarts Tootsie rolls Candy corn Gummy bears Lollipops Candy bars Other candies Gum Marshmallows Cookies Graham crackers Cake Other crackers Cereal Pretzels Popcorn Chips Pudding Yogurt Bagels Pizza French fries Onion rings Cheese Peanut butter Raisins Grapes Apples Bananas Other fruit Carrots Other vegetables Ice Cream Juice Soda Snow cones Kool Aid Chocolate milk Other: Reinforcer Assessment: Paired Stimulus Before starting assessment: Stimuli should be selected based upon availability, ease of presentation, parent/staff reports, and any on dietary and health restrictions for the student. Make sure student has sampled items previously and none are unfamiliar. If a stimulus is new, allow student access before the assessment begins. Set-Up: Before each session, place a cleared off table to use for the assessment. Have materials available to record data from assessment. Assessment: Put two stimuli on the table in front of the child (0.7 m from one another and 0.7 m from the child) and wait for 5 s. If the child touches a stimulus, remove the non-chosen stimulus immediately. Let the child interact with the chosen stimulus for 5 s. If the child samples the stimulus at the first opportunity, move on to Step 9. If the child approaches both stimuli, block him or her by holding the two stimuli down on the table. If the child does not approach both stimuli after 5 s, prompt him or her to sample each stimulus for 5 s. For an edible stimulus, put the stimulus in front of the childs mouth. For a toy, let the child hold the stimulus for 5 s. After the child samples both stimuli, present the two stimuli again. (Note that this still constitutes the same trial.) Repeat steps 2-4. If the child does not approach both stimuli, again remove the stimuli. Record the data for each trial by writing the results on the score sheet provided. In each stimulus preference assessment session, each stimulus was paired once with every other stimulus. For example, with 7 stimuli, there are a total of 21 trials in each session. # of stimuli45678910# of trials6101521283645# of times chosen / # of trials presented (total number of stimuli 1) Data Sheet Date: Trial #StimulusStimulusChosen123456789101112131415161718192021222324252627282930313233343536373839404142434445Stimulus# chosen# present% rank           # of stimuliPossible %41/3 (33, 66, 99)51/4 (25, 50, 75, 100)61/5 (20, 40, 60, 80, 100)71/6 (16, 33, 50, 66, 83, 100)81/7 (14, 28, 42, 57, 71, 85, 100)91/8 (12, 25, 37, 50, 62, 75, 87, 100)     Adapted from materials by Beautiful Minds of Princeton L.L.C. 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