Procedural Fidelity Checklist Form
Procedural Fidelity Checklist Form
Observer Name
*
First Name
Last Name
Assessment Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Procedure Being Observed
*
Step-by-Step Fidelity Assessment
*
Rows
Completed
Not Completed
Not Applicable
Step 1: Preparation
1
2
3
Step 2: Instruction Delivery
4
5
6
Step 3: Response Monitoring
7
8
9
Step 4: Feedback Provided
10
11
12
Step 5: Procedure Closure
13
14
15
Overall Fidelity Rating
*
1
2
3
4
5
Fidelity Checklist Items (Select all that apply)
All materials prepared in advance
Instructions delivered as written
Corrective feedback provided
Data recorded accurately
Other
Comments or Notes
Submit Checklist
Should be Empty: