Treatment Integrity Checklist Form
Use this form to record observations and ensure treatment procedures are followed accurately and consistently.
Observer Name
*
First Name
Last Name
Date of Observation
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Staff Observed
*
First Name
Last Name
Session or Activity Observed
*
Treatment Steps Checklist (Mark all steps observed as completed)
*
Reviewed session goals at start
Followed prescribed intervention procedures
Provided feedback/reinforcement as outlined
Collected required data accurately
Maintained professional conduct throughout
Other (please specify)
Were all required materials prepared and available?
Yes
No
Were any deviations from the protocol observed?
No deviations observed
Minor deviations (did not impact session)
Major deviations (impacted session)
Notes or Comments
Submit Checklist
Should be Empty: