1. Does the problem behavior occur when the Yes No N/A

person is not receiving attention or when

caregivers are paying attention to someone else?

2. Does the problem behavior occur when the Yes No N/A

person's requests for preferred items or

activities are denied or when these are taken

away?

3. When the problem behavior occurs, do care- Yes No N/A

givers usually try to calm the person down or

involve the person in preferred activities?

4. Is the person usually well behaved when (s)he

is getting lots of attention or when preferred Yes No N/A

activities are freely available?

5. Does the person usually fuss or resist when Yes No N/A

(s)he is asked to perform a task or to participate

in activities?

6. Does the problem behavior occur when the Yes No N/A

person is asked to perform a task or to

participate in activities?

7. If the problem behavior occurs while tasks are Yes No N/A

being presented, is the person usually given a

"break" from tasks?

8. Is the person usually well behaved when (s)he Yes No N/A

is not required to do anything?

9. Does the problem behavior occur even when no

one is nearby or watching? Yes No N/A

10. Does the person engage in the problem behavior Yes No N/A

even when leisure activities are available?

11. Does the problem behavior appear to be a form

of "self-stimulation?" Yes No N/A

12. Is the problem behavior less likely to occur Yes No N/A

when sensory stimulating activities are

presented?

13. Is the problem behavior cyclical, occurring for Yes No N/A

several days and then stopping?

14. Does the person have recurring painful Yes No N/A

conditions such as ear infections or allergies?

If so, list:

15. Is the problem behavior more likely to occur Yes No N/A

when the person is ill?

16. If the person is experiencing physical problems, Yes No N/A

and these are treated, does the problem behavior

usually go away?