Self-care routines Leisure activities Academic skills training Work/vocational training Meals Evenings

The following questions refer to the individual's behavior. Read each question carefully and answer "Yes" or "No."

	Yes	No
1. The behavior usually occurs in your presence or in the presence of others
2. The behavior usually occurs soon after you or others interact with him/her in some way, such as delivering an instruction or reprimand, walking away from (ignoring) the him/her, taking away a "preferred" item, Yes No requiring him/her to change activities, talking to someone else in his/her presence, etc.
3. The behavior often is accompanied by other "emotional" responses, such as yelling or crying

	Yes	No
4. The behavior often occurs when he/she has not received much attention
5. When the behavior occurs, you or others usually respond by interacting with the him/her in some way (e.g., comforting statements, verbal correction or reprimand, response blocking, redirection)
6. (S)he often engages in other annoying behaviors that produce attention
7. (S)he frequently approaches you or others and/or initiates social interaction
8. The behavior rarely occurs when you give him/her lots of attention
9. The behavior often occurs when you take a particular item away from him/her or when you terminate a preferred leisure activity (If yes, identify below)
10. The behavior often occurs when you inform the person that (s)he cannot have a certain item or cannot engage in a particular activity. (If yes, identify below)
11. When the behavior occurs, you often respond by giving him/her a specific item, such as a favorite toy, food, or some other item. (If yes, identify below)
12. (S)he often engages in other annoying behaviors that produce access to preferred items or activities.
13. The behavior rarely occurs during training activities or when you place other types of demands on him/her. (If yes, identify below)
14. The behavior often occurs during training activities of when asked to complete tasks.
15. (S}he often is noncompliant during training activities or when asked to complete tasks.
16. The behavior often occurs when the immediate environment is very noisy or crowed.
17. When the behavior occurs, you often respond by giving him/her brief "break from an ongoing task.
18. The. behavior rarely occurs when you place few demands on him/her or when you leave him/her alone.

	Yes	No
19. The behavior occurs frequently when (s}he is alone or unoccupied
20. The behavior occurs at relatively high rates regardless of what is going on in his/her immediate surrounding environment
21. (S}he seems to have few known reinforcers or rarely engages in appropriate object manipulation or "play' behavior.
22. (S}he is generally unresponsive to social stimulation.
23. (S }he often engages in repetitive, stereotyped behaviors such as body rocking, hand or finger waving, object twirling, mouthing, etc.
24. When (s}he engages in the behavior, you and others usually respond by doing nothing (Le., you never or rarely attend to the behavior.)
25. The behavior seems to occur in cycles. During a "high" cycle, the behavior occurs frequently and is extremely difficult to interrupt. During a ~'Iow' cycle the behavior rarely occurs.
26. The behavior seems to occur more often when the person is ill.
27. (S}hehas a history of recurrent illness (e.g., ear or sinus infections, allergies, dermatitis).

The following questions are based on your answers from above.

Self-care Academic Work

Likely Maintaining Variable

Adapted from the Florida Center on Self-Injury

FAST: Functional Analysis Screening Tool

Information about the Problematic Behavior