Reinforcement assessment form

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REINFORCEMENT ASSESSMENT FORM

Student’s Name:______________________ Completed By:_____________________ Date:________________

Prior to beginning the pairing process, it is important to identify ALL of your student’s 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 student’s preferences below. Please provide specifics if possible (e.g., what kind, brand, type, etc.). Cross off (X) if student hates.
What are your student’s 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 student’s entertainment preferences?


Movies:


TV:

Animation/Cartoons:

Music:


Video Games:

Board Games/Other:

List some of your student’s 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 student’s favorite CD ROM Games:

List your student’s 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 principal’s 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 student’s outdoor activities?

Bicycle:

Swing Set:

Trampoline:


Theme Parks:

Swimming:

Slide:


Other Notes:

What are your student’s 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 student’s favorite snacks/foods?

Candy:

Fruit:


Cookies:

Crackers:


Chips:

Pretzels:


Ice Cream:

Other:
List your student’s favorite brand names:

What are your student’s favorite beverages?



Soda:

Juice:

Water:


Milk:

List your student’s favorite flavors and brand names:
Other:

Having a snack M & M’s 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:


  1. Stimuli should be selected based upon availability, ease of presentation, parent/staff reports, and any on dietary and health restrictions for the student.

  2. 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:


  1. Before each session, place a cleared off table to use for the assessment. Have materials available to record data from assessment.


Assessment:


  1. 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.

  2. If the child touches a stimulus, remove the non-chosen stimulus immediately.

  3. 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.

  4. If the child approaches both stimuli, block him or her by holding the two stimuli down on the table.

  5. 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 child’s mouth. For a toy, let the child hold the stimulus for 5 s.

  6. After the child samples both stimuli, present the two stimuli again. (Note that this still constitutes the same trial.)

  7. Repeat steps 2-4.

  8. If the child does not approach both stimuli, again remove the stimuli.

  9. 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 stimuli

4

5

6

7

8

9

10

# of trials

6

10

15

21

28

36

45

# of times chosen / # of trials presented (total number of stimuli – 1)

Data Sheet
Date:


Trial #

Stimulus

Stimulus

Chosen

1










2








3










4










5










6










7










8










9










10










11










12








13











14










15










16










17










18










19










20










21










22










23








24










25










26










27










28










29










30










31










32










33








34











35










36










37










38










39










40










41










42










43










44








45










Stimulus

# chosen

# present

% rank















































































































# of stimuli

Possible %

4

1/3 (33, 66, 99)

5

1/4 (25, 50, 75, 100)

6

1/5 (20, 40, 60, 80, 100)

7

1/6 (16, 33, 50, 66, 83, 100)

8

1/7 (14, 28, 42, 57, 71, 85, 100)

9

1/8 (12, 25, 37, 50, 62, 75, 87, 100)




Adapted from materials by Beautiful Minds of Princeton L.L.C.




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