Scoring Summary

Circle the number of each question that was answered "Yes" and

enter the number of items that were circled in the "Total" column.

Items Circled "Yes" Total Potential Source of Reinforcement

1 2 3 4 Social (attention/preferred items)

5 6 7 8 Social (escape from tasks/activities)

9 10 11 12 Automatic (sensory stimulation)

13 14 15 16 Automatic (pain attenuation)