About the individual:

Name: __________________________________________ Telephone: ___________________________

Current or Highest Grade Completed (if applicable):

___________________________________________

Language Spoken at Home:

_______________________________________________________________

Does the individual have any disabling conditions? ____________________________________________

Sex (circle one): F M

Year Month Day

Test Date: _________ __________ __________

Birth Date: _________ __________ __________

Chronological Age: _________ __________ __________

Record
Booklet

Parental/Caregiver Rating Form

Sara S. Sparrow, Domenic V. Cicchetti and David A. Balla
A revision of the Vineland Social Maturity Scale by Edgar A. Doll

About the Respondent:

Name: ________________________________________________ Sex: ___________________________

Relationship to Individual: __________________________Telephone: ____________________________

Directions:
This booklet contains phrases that describe many different behaviors that people show at home, school,
work or other settings. The behaviors range from those appropriate fror infantsto those appropriate for
adults. Some may be too hard for younger children and some may be too easy for older children or for
adults. Thus, the child, adolescent or adult you are rating may not show all the behaviors described in
the items.

In each section, find the starting point (Start Ages: 0-5) for the individual’s age. Read each phrase and
mark the response that best describes the individual’s behavior. The response that you choose should
reflect how often the individual performs the behavior without help, when the behavior is needed. Mark
your scores in this booklet by circling one response option for each item.

 Circle “2” if the individual usually performs the behavior without help or reminders.
 Circle “1” if the individual sometimes performs the behavior without help or reminders or
partially performs the behavior without help or reminders.
 Circle “0” if the individual never performs the behavior or never performs it without help or
reminders.
 If you have never seen the individual perform a behavior and don’t know whether he or she
performs it circle DK for Don’t Know.
 If an item has a Scoring Tip, use the tip to help you decide which response option to circle.
 If an item has a Scoring Tip that says you may circle “N/O” No Opportunity, you may circle the
option, if appropriate, instead of a “2,” ”1,” ”0” or “DK.”
 Some sections do not apply to children younger than 3 years of age. If the child you are rating is
younger than the age of the first starting point, do not mark any items in that section.
 Here is an example: In this
column,
circle your
response.
Circle
“?” If you
have any
Questions
.
Starting Demonstrates understanding of function of telephone (for 2
1 1 0 DK ?
Ages (1-9) example, pretends to talk on phone, etc.)
2 Talks to familiar person on phone. 2 1 0 DK ?
Uses TV or Radio without help (for example, turns
Watch for additional equipment on, accesses channel or station, selects program,
3 etc.).
2 1 0 DK ?
scoring information
sometimes
SCORING TIP: You may not mark “N/O” for No Opportunity N/O
if there is no TV or radio in the home.
4 Counts at least 10 objects, one by one. 2 1 0 DK ?
Is aware of and demonstrates appropriate behavior while 1 DK ?
5 riding in car (for example, keeps seat belt on, refrains from 2 0
distracting driver, etc.).

If you don’t know If you have a

whether the question, score the
individual performs item and then circle
the behavior, circle the question mark.
DK.

Directions continued…

 If you want to change a response, mark an X through it and circle your new choice.
 If you have a question about any item, first mark the response that best describes the
individual’s behavior and then circle the question mark (?) to the right of the response options.
 Use the following table to help you choose the response that best describes the behavior of the
individual you are rating:

RATING THE INDIVIDUAL

Usually performs the behavior without help or reminders when it is needed; or

2
Usually Performed the behavior at a younger age but now has outgrown it.

Sometimes performs the behavior without help or reminders when it is needed; or

1 Sometimes does without help but sometimes needs help; or
Sometimes or
Sometimes does without help but needs reminders; or
Partially
Performs part of the behavior without help of reminders.

Never performs the behavior without help or reminders; or

Never Performs the behavior because he or she is unable; or
Never performs the behavior, because he or she is too young; or
0
Never Never performs the behavior, because he or she is not allowed to; or
Never performs the behavior because he or she has a physical disability that prevents the
behavior.
 Communication
Response Options: 2 = Usually, 1 = Sometimes or Partially, 0 = Never, DK = Don’t Know

Circle “?”
If You
Listening and Understanding Have a
Question

Start
Ages 1 Turns eye and head toward sound. 2 1 0 DK ?
0-4
Looks toward parent or caregiver when hearing parent’s or caregiver’s
2 2 1 0 DK ?
voice.
Responds to his or her name spoken (for example, turns toward a speaker,
3 2 1 0 DK ?
smiles, etc.)
Demonstrates understanding of the mean of no, or word or gesture with
4 2 1 0 DK ?
the same meaning (for example, stops current activity briefly).
Demonstrates understanding of the mean of yes, or word or gesture with
5 2 1 0 DK ?
the same meaning (for example, continues activity, smiles, etc.)
Listens to story for at least 5 minutes (that is, remains relatively still and
6 2 1 0 DK ?
directs attention to the storyteller or reader).
Points to at least three major body parts when asked (for example, nose,
7 2 1 0 DK ?
mouth, hands, feet, etc.).
Start
Points to common objects in a book or magazine as they are named (for
Ages 8 2 1 0 DK ?
5+ example, dog, car, cup, key, etc.)

9 Listens to instructions. 2 1 0 DK ?

Follows instructions with one action and one object (for example, “Bring
10 2 1 0 DK ?
me the book”; “Close the door”; etc.).

Points to at least five minor body parts when asked (for example, fingers,
11 2 1 0 DK ?
elbows, teeth, toes, etc.).

Follows instructions with two actions or an action and two objects (for
12 example, “Bring me the crayons and the paper”; “Sit down and eat your 2 1 0 DK ?
lunch”; etc.).
Follows instructions in “if-then” form (for example, “if you want too play
13 2 1 0 DK ?
outside, then put your things away”; etc.).

14 Listens to a story for at least 15 minutes. 2 1 0 DK ?

15 Listens to a story for at least 30 minutes. 2 1 0 DK ?

 Follows three-part instructions (for example, “Brush your teeth, get
16 2 1 0 DK ?
dressed, and make your bed”; etc.).
17 Follows instructions or directions heard 5 minutes before. 2 1 0 DK ?
Understands sayings that are not meant to be taken word for word (for
18 2 1 0 DK ?
example, “Button your lip”; “Hit the road”; etc.).

19 Listens to an informational talk for at least 15 minutes. 2 1 0 DK ?

20 Listens to an informational talk for at least 30 minutes. 2 1 0 DK ?

Circle “?”
If You
Talking Have a
Question

Start
Ages 0-4 1 Cries or fusses when hungry or wet. 2 1 0 DK ?

2 Smiles when you smile at him or her. 2 1 0 DK ?

3 Makes sounds of pleasure (for example, coos, laughs, etc.). 2 1 0 DK ?

4 Make nonword baby sounds (that is, babbles). 2 1 0 DK ?

Makes sounds or gestures (for example, waves arms) to get parent’s or
5 2 1 0 DK ?
caregiver’s attention.
Makes sounds or gestures (for example, shakes head) if he or she
6 2 1 0 DK ?
wants an activity to stop or keep going.
Waves good-bye when another person waves or parent or caregiver
7 2 1 0 DK ?
tells him or her to wave.
Says “Da-da,” “Ma-ma,” or another name for parent or caregiver
8 2 1 0 DK ?
(including parent’s or caregiver’s first name or nickname).

9 Points to object he or she wants that is out of reach. 2 1 0 DK ?

Points or gestures to indicate preference when offered a choice (for

10 2 1 0 DK ?
example, “Do you want this one or that one?”; etc.).
Repeats or tries to repeat common words immediately upon hearing
11 2 1 0 DK ?
them (for example, ball, car, go, etc.).
Names at least three objects (for example, bottle, dog, favorite toy,
12 2 1 0 DK ?
etc.).

13 Says one-word requests (for example, up, more, out, etc.). 2 1 0 DK ?

Uses first names or nicknames of brothers, sister, or friends, or says

14 2 1 0 DK ?
their names when asked.
 15 Answers or tries to answer with words when asked a question. 2 1 0 DK ?

16 Names at least 10 objects. 2 1 0 DK ?

States own first name or nickname (for example, Latesha, Little Sister,
17 2 1 0 DK ?
etc.) when asked.
Uses phrases with a noun and a verb (for example, “Katie stay”; “Go
18 2 1 0 DK ?
home”; etc.).
Ask questions by changing inflection of words or simple phrases
19 2 1 0 DK ?
(“Mine?”; “Me go?”; etc.); grammar is not important.

20 Says at least 50 recognizable words. 2 1 0 DK ?

Uses simple words to describe things (for example, dirty, pretty, big,
21 2 1 0 DK ?
loud, etc.).
Asks questions beginning with what or where (for example, “What’s
22 2 1 0 DK ?
that?”; “Where doggie go?”; etc.).

Uses negatives in sentences (for example, “Me no go”; “I won’t drink

23 2 1 0 DK ?
it”; etc.); grammar is not important.

Tells about experiences in simple sentences (for example, “Ginger and I

24 2 1 0 DK ?
play”; “Dan read me a book”; etc.).
Start
Ages 5- 25 Says correct when asked. 2 1 0 DK ?
13

26 Says at least 100 recognizable words. 2 1 0 DK ?

Uses in, on, or under in phrases or sentences (for example, “Ball go

27 2 1 0 DK ?
under chair”; “Put it on the table”; etc.).
Uses and in phrases or sentences (for example “Mom and Dad”; “I
28 2 1 0 DK ?
want ice cream and cake”; etc.).

29 Says first and last name when asked. 2 1 0 DK ?

Identifies and names most common colors (that is, red, blue, green,
yellow, orange, purple, brown and black).
30 SCORING TIP: Mark a “2” if the individual names 6 to 8 colors; mark a “1” of 2 1 0 DK ?
the individual names 2 to 5 colors; mark a “0” if the individual names 0 to 1
color.
Asks questions beginning with who or why (for example, “Who’s
31 2 1 0 DK ?
that?”; “Why do I have to go?”; etc.)

Uses present tense verbs ending in -ing (for example, “Is singing”; “Is
32 2 1 0 DK ?
playing”; etc.).
 Uses possessives in phrases or sentences (for example, “That’s her
33 2 1 0 DK ?
book”; “This is Carlos’ Ball”; etc.).
Uses pronouns in phrases or sentences; must use correct gender and
34 form of the pronoun, but sentences need not be grammatically correct 2 1 0 DK ?
(for example, “He done it.”; “They went”; etc.).

Asks questions beginning with when (for example, “When is dinner?”;

35 2 1 0 DK ?
“When can we go home?”; etc.).
Uses regular past tense verbs (for example, walked, baked, etc.); may
36 use irregular past tense verbs ungrammatically (for example, “I runned 2 1 0 DK ?
away”; etc.).
Uses behind or in front of in phrases or sentences (for example, “I
37 2 1 0 DK ?
walked in front of her”; “Terrel is behind you”; etc.).
Pronounces words clearly without sound substitutions (for example,
38 2 1 0 DK ?
does not say “wabbit” for “rabbit,” “Thally” for “Sally,” etc.).
Tells basic parts of a story, fairy tale or television show plot; does not
39 2 1 0 DK ?
need to include great detail or recount in perfect order.
Start
Ages 14+
40 Says month and day of birthday when asked. 2 1 0 DK ?

Modulates tone of voice, volume and rhythm appropriately (for

41 example, does not consistently speak too loudly, too softly or in a 2 1 0 DK ?
monotone, etc.).
Tells about experiences in detail (for example, tells who was involved
42 2 1 0 DK ?
where activity took place, etc.).
Gives simple directions (for example, on how to play a game or to
make something).
43 SCORING TIP: Mark a “2” if the directions are clear enough to follow; mark a 2 1 0 DK ?
“1” if the individual articulates the directions but they are not clear enough to
follow; mar a “0” if the individual never attempts to articulate directions.

Uses between in phrases or sentences (for example, “The ball went

44 2 1 0 DK ?
between the cars”; etc.).

45 Says own telephone number when asked. 2 1 0 DK ?

46 Easily moves from one topic to another in conversation. 2 1 0 DK ?

47 Stays on topic in conversations; does not go off on tangents. 2 1 0 DK ?

Explains ideas in more than one way (for example, “This was a good
48 2 1 0 DK ?
book. It was exciting and fun to read”; etc.).

Has conversations that last 10 minutes (for example, relates

49 2 1 0 DK ?
experiences, contributes ideas, shares feelings, etc.).
 Uses irregular plurals correctly (for example, children, geese, mice,
50 2 1 0 DK ?
women, etc.).
Uses complete home address (that is, street or rural route, apartment
51 2 1 0 DK ?
number, city and state), with or without zip code, when asked.

Describes a short-term goal and what he or she needs to do to reach it

52 (for example, says, “I want to get an A on my test, so I’m going to study 2 1 0 DK ?
hard”; etc.).
Gives complex directions to others (for example, to a distant location,
for recipe with many ingredients or steps, etc.).
53 Scoring Tip: Mark a “2” if the directions are clear enough to follow; mark a 2 1 0 DK ?
“1” if the individual articulates directions but they are not clear enough to
follow; mark a “0” if the individual never attempts to articulate directions.
Describes a realistic long-range goal that can be done in 6 months or
54 more (for example, says, “I want to buy a bike, so I’ll babysit and run 2 1 0 DK ?
errands to earn enough money to buy it.”; etc.).

Communication, continued
Response Options: 2 = Usually, 1 = Sometimes or Partially, 0 = Never, DK = Don’t Know
Circle “?” If
Reading and Writing You Have a
Question

Start Ages Identities one or more alphabet letters as letters and distinguishes
3-13 1 2 1 0 DK ?
them from numbers.
2 Recognizes own name in printed form. 2 1 0 DK ?

3 Identifies at least 10 printed letters of the alphabet. 2 1 0 DK ?

Prints or writes using correct orientation (for example, in English
4 from left to right; in some languages from right to left or top to 2 1 0 DK ?
bottom).
5 Copies own first name. 2 1 0 DK ?
6 Identifies all printed letters of the alphabet, upper- and lowercase. 2 1 0 DK ?
Prints at least three simple words from example (for example, cat,
7 2 1 0 DK ?
see, bee, etc.).

8 Prints or writes own first and last name from memory. 2 1 0 DK ?

9 Reads at least 10 words aloud. 2 1 0 DK ?

10 Prints at least 10 simple words from memory. 2 1 0 DK ?

 Reads simple stories aloud (that is, stories with sentences of three
11 2 1 0 DK ?
to five words).
Prints simple sentences of three or four words; may make small
12 2 1 0 DK ?
errors in spelling or sentence structure.
Prints more than 20 words from memory; may make small spelling
13 2 1 0 DK ?
errors.
Start Ages
14+ 14 Reads and understands material of at least second-grade level. 2 1 0 DK ?

15 Puts lists of words in alphabetical order. 2 1 0 DK ?

Writes simple correspondence at least three sentences long (for
16 2 1 0 DK ?
example, postcards, thank-you notes, email, etc.).
17 Reads and understands material of at least fourth grade level. 2 1 0 DK ?
Writes reports, papers or essays at least one page long; may use
18 2 1 0 DK ?
computer.
Writes complete mailing and return addresses on letters or
19 2 1 0 DK ?
packages.
20 Reads and understands material of at least sixth-grade level. 2 1 0 DK ?

Edits or corrects own written work before handing it in (for

21 2 1 0 DK ?
example, checks punctuations, spelling, grammar, etc.).
Writes advanced correspondence at least 10 sentences long; may
22 2 1 0 DK ?
use computer.
23 Reads and understands material of at least ninth-grade level. 2 1 0 DK ?
Reads at least two newspaper articles weekly (print or electronic
24 2 1 0 DK ?
version)
Writes business letters (for example, requests information, makes
25 2 1 0 DK ?
complaint, places order, etc.); may use computer.
 Daily Living
Response Options: 2 = Usually, 1 = Sometimes or Partially, 0 = Never, DK = Don’t Know
Circle “?”
If You
Have a
Question
Start
1 Opens mouth when food is offered. 2 1 0 DK ?
Ages 0-8
Eats solid foods (for example, cooked vegetables, chopped meats,
2 2 1 0 DK ?
etc.).
Sucks or chews on finger foods (for example, crackers, cookies,
3 2 1 0 DK ?
toast, etc.).

4 Drinks from a cup or glass; may spill. 2 1 0 DK ?

Lets someone know when he or she has wet or soiled diaper or

5 2 1 0 DK ?
pants (for example, points, vocalizes, pulls at diaper, etc.).

6 Feeds self with spoon; may spill. 2 1 0 DK ?

7 Sucks from straw. 2 1 0 DK ?

Takes off clothing that opens in the front (for example, a coat or
8 2 1 0 DK ?
sweater); does not have to unbutton or unzip clothing.
Pulls up clothing with elastic waistbands (for example, underwear
9 2 1 0 DK ?
or sweatpants).

10 Feeds self with fork; may spill. 2 1 0 DK ?

11 Drinks from a cup or glass without spilling. 2 1 0 DK ?

12 Feeds self with spoon without spilling. 2 1 0 DK ?

13 Urinates in toilet or potty chair. 2 1 0 DK ?

Puts on clothing that opens in the front (for example, a coat or

14 2 1 0 DK ?
sweater); does not have to zip or button the clothing.

15 Asks to use toilet. 2 1 0 DK ?

16 Defecates in toilet or potty chair. 2 1 0 DK ?

Is toilet-trained during the day.

Scoring Tip: Mark “2” if the individual uses toilet without help and
17 without accidents; mark “1” if the individual needs help, such as with 2 1 0 DK ?
wiping or has some accidents; mark “0” if the individual always needs
help or has frequent accidents.
 Zips zippers that are fastened at the bottom (for example, in
18 2 1 0 DK ?
pants, on backpacks, etc.).

19 Wipes or blows nose using tissue or handkerchief. 2 1 0 DK ?

20 Is toilet-trained during the night. 2 1 0 DK ?

21 Puts shoes on correct feet; does not need to tie laces. 2 1 0 DK ?

22 Fastens snaps. 2 1 0 DK ?

Start Ages
9+
23 Holds spoon, fork and knife correctly. 2 1 0 DK ?

24 Washes and dries face using soap and water. 2 1 0 DK ?

Brushes teeth.
Scoring Tip: Mark a “2” if the individual brushes teeth without help,
including putting toothpaste on the brush and without being told to
25 2 1 0 DK ?
brush; mark “1” if the individual needs help brushing or putting
toothpaste on the brush or needs frequent reminders; mark “0” if the
individual never brushes without help or without being reminded.

26 Buttons large buttons in front, in correct buttonholes. 2 1 0 DK ?

27 Covers mouth and nose when coughing and sneezing. 2 1 0 DK ?

28 Buttons small buttons in front, in correct buttonholes. 2 1 0 DK ?

Connects and zips zippers that are not fastened at the bottom
29 2 1 0 DK ?
(for example, in jackets, sweatshirts, etc.).
Turns faucets on and adjusts temperature by adding hot or cold
30 2 1 0 DK ?
water.
Wears appropriate clothing during wet or cold weather (for
31 2 1 0 DK ?
example, raincoat, boots, sweater, etc.).
Bathes or showers and dries self.
Scoring Tip: Mark a “2” if the individual bathes or showers without
help, including turning the water on and off; mark a “1” if the individual
32 2 1 0 DK ?
needs help with any part of bathing or drying or with turning the water
on and off; mark “0” if the individual never bathes or showers without
help or without reminders.

33 Finds and uses appropriate public restroom for his or her gender. 2 1 0 DK ?

34 Washes and dries hair (with towel or hair dryer). 2 1 0 DK ?

Cares for minor cuts (for example, cleans would, puts on

35 2 1 0 DK ?
bandage, etc.).
 36 Takes medicine as directed (that is, follows directions on label). 2 1 0 DK ?

37 Uses thermometer to take own or another’s temperature. 2 1 0 DK ?

Seeks medical help in an emergency (for example, recognizes

symptoms of serious illness or injury, such as shortness of breath, 2 1 0
38 chest pain, uncontrolled bleeding, etc.). DK ?
Scoring Tip: You may mark “N/O” for no opportunity if the individual N/O
has not been in a medical emergency.
Follows directions for health care procedures, special diet or
medical treatments. 2 1 0
39 Scoring Tip: You may mark “N/O” for No Opportunity if the individual DK ?
does not have a health concern that requires special procedures, diet or N/O
treatments.
Keeps track of medications (nonprescription and prescription)
40 2 1 0 DK ?
and refills them as needed.

41 Makes appointments for regular medical and dental checkups 2 1 0 DK ?

Circle “?”
If You
Have a
Question

Start Ages Is careful around hot objects (for example, the stove or oven, an
1-13
1 2 1 0 DK ?
open fire, etc.).
Helps with simple household chores (for example, dusts, picks up
2 2 1 0 DK ?
clothes or toys, feeds pet, etc.).

3 Clears unbreakable items from own place at table. 2 1 0 DK ?

Cleans up play or work area at end of an activity (for example,

4 2 1 0 DK ?
finger painting, model building, etc.).
Puts away personal possessions (for example, toys, books,
5 2 1 0 DK ?
magazines, etc.).
Is careful when using sharp objects (for example, scissors, knives,
6 2 1 0 DK ?
etc.)

7 Clears breakable items from own place at table. 2 1 0 DK ?

Start Ages Helps prepare foods that require mixing and cooking (for example,
14+
8 2 1 0 DK ?
cake or cookie mixes, macaroni and cheese, etc.).
 Uses simple appliances (for example, a toaster, can opener, bottle
9 2 1 0 DK ?
opener, etc.).
Uses microwave oven for heating, baking, cooking (that is, sets 2 1 0
time and power setting etc.
10 DK ?
Scoring tip: You may mark ‘N/O’ for No Opportunity if there is no
N/O
microwave in the home.

Puts clean clothes away in proper place (for example, in drawers ?

11 2 1 0 DK
or closet, on hooks etc.)
Uses tools (for example, a hammer to drive nails, a screwdriver to ?
12 2 1 0 DK
screw and unscrew screws, etc.)

13 Washes dishes by hand, or loads and uses dishwasher. 2 1 0 DK ?

Sweeps, mops, or vacuums floors thoroughly. 2 1 0

Scoring tip: Mark ‘2’ if the individual moos, sweeps or vacuums so well
that the task does not have to redone; mark ‘1’ if the individual doesn’t DK ?
14
consistently complete the task well; mark ‘0’ if the individual never mops,
sweeps or vacuums or does the task so poorly that it always needs to be N/O
redone.

Clears table completely (for example, scrapes and stacks dishes,

15 2 1 0 DK ?
throws away disposable items, etc.)
Uses household products correctly (for example laundry
16 2 1 0 DK ?
detergent, furniture polish, glass cleaner etc.)
Prepares basic food that do not need mixing but require cooking
17 2 1 0 DK ?
(for example, rice, soup, vegetables etc.)
18 Cleans one or more room other than bedroom. 2 1 0 DK ?
19 Uses sharp knife to prepare food. 2 1 0 DK ?
Uses stove or oven for heating, baking or cooking (that is, turns
20 2 1 0 ?
burners on and off, sets oven temperature etc.) DK
Prepares food from ingredients that require measuring, mixing and
21 2 1 0 DK ?
cooking.
22 Washes clothing as needed. 2 1 0 DK ?
Performs maintenance tasks as needed (for example, replaces light
2 1 0 DK ?
23 bulbs, changes vacuum cleaner bag etc.)

24 Plans and prepares main meal of the day. 2 1 0 DK ?

Circle “?”
If you
have a
Question
Start Ages Demonstrates understanding of function of telephone (for
1-9
1
example, pretends to talk on phone etc.) 2 1 0 DK ?
2 Talks to familiar person on telephone. 2 1 0 DK ?
Uses TV or radio without help (for example, turns equipment on,
accesses channel or station, selects program, etc.)
3 2 1 0 DK ?
Scoring tip: You may mark ‘N/O’ for No Opportunity if there is no
Tv or radio in the home.

4 Counts at least 10 objects, one by one. 2 1 0 DK ?

Is aware of and demonstrates appropriate behavior while riding in

5 car (for example, keeps seat belt on, refrains from distracting 2 1 0 DK ?
driver etc.)
Demonstrates understanding of the function of money (for
6 example, says, ‘Money is what you need to buy things at the store’ 2 1 0 DK ?
etc.
Uses sidewalk (where available) or shoulder of road when walking
7 2 1 0 DK ?
or using wheeled equipment (skates, scooter, tricycle, etc.)
Demonstrates understanding of function of clock (for example,
8 2 1 0 DK ?
says, ‘Clocks tell time’, ‘What time can we go?’ etc.
Follows household rules (for example, no running in the house, no
9 2 1 0 DK ?
jumping on the furniture, etc.)
Demonstrates computer skills necessary to play games or start
2 1 0
programs with computer turned on, does not need to turn
10 computer on by self. DK ?
Scoring tip: You may mark ‘N/O’ for No Opportunity if there is no N/O
computer in the home.
Summons to the telephone the person receiving a call or indicates
11 2 1 0 DK ?
that the person is not available.
Start
Identifies penny, nickel, dime, quarter by name when asked; does
Ages 12 2 1 0 DK ?
not need to know the value of coins.
10-15
13 Looks both ways when crossing streets or roads. 2 1 0 DK ?

14 Says current day of the week when asked. 2 1 0 DK ?

Demonstrates understanding of right to personal privacy for self

and others (for example, while using restroom or changing clothes, 2 1 0 DK ?
15
etc.)

Demonstrates knowledge of what phone number to call in an

16 2 1 0 DK ?
emergency when asked.

17 Tells time using a digital clock or watch. 2 1 0 DK ?

 States value of penny (1 cent), nickel (5 cents) dime (10 cents) and
2 1 0 DK ?
18 quarter (25 cents).

Discriminates between bills of different denominations (for

2 1 0 DK ?
19 example, refers to $1 bills, $5 bills etc. in conversation etc.)

20 Obeys traffic lights and Walk and Don’t Walk signs. 2 1 0 DK ?

21 Points to current or other date on calendar when asked. 2 1 0 DK ?

Demonstrates understanding that some items cost more than

others (for example, says, ‘I have enough money to buy gum but 2 1 0 DK ?
22
not a candy bar’; ‘Which pencil costs less?’ etc.)
Start
Tells time by the half hour on analog clock (for example,1:30, 2:00,
Ages 23 2 1 0 DK ?
etc.)
16+
24 Makes telephone calls to others, using standard or cell phone. 2 1 0 DK ?

Orders a complete meal in a fast-food restaurant. 2 1 0

25 Scoring tip: You may mark ‘N/O’ for No Opportunity if the individual has DK ?
never eaten at a fast-food restaurant. N/O
Carries or stores money safely (for example, in wallet, purse,
26 2 1 0 DK ?
money belt, etc.)
Tells time by 5-minute segments on analog clock (for example,
27 2 1 0 DK ?
1:05, 1:10, etc.)
28 Obeys curfew parent or caregiver sets. 2 1 0 DK ?
Watches or listens to programs for information (for example, 2 1 0
weather, report, news, educational program, etc.)
29 DK
Scoring Tip: You may mark ‘N/O’ for No Opportunity if there is no Tv or ?
radio in the home. N/O

30 Counts change from a purchase. 2 1 0 DK ?

Demonstrates computer skills necessary to carry out complex
tasks (for example, word processing, accessing the internet, 2 1 0
31 installing software, etc.) DK
?
Scoring Tip: You may mark ‘N/O’ for No Opportunity if there is no
N/O
computer in the home.

32 Evaluates quality and price when selecting items to purchase. 2 1 0 DK ?

Obeys time limits for breaks (for example, lunch or coffee breaks,
33 2 1 0 DK ?
etc.)
Travels at least 5 to 10 miles to familiar destination (that is, bikes,
34 2 1 0 DK ?
uses public transportation, or drives self.)

Demonstrates understanding of right to complain or report

35 2 1 0 DK ?
legitimate problems when dissatisfied with services or situations.
 36 Notifies school or supervisor when he or she will be late or absent. 2 1 0 DK ?

Uses savings or checking account responsibly (for example, keeps

37 2 1 0 DK ?
some money in account, tracks balance carefully, etc.)

Travels at least 5 to 10 miles to unfamiliar destination (that is,

38 2 1 0 DK ?
bikes, uses public transportation, or drives self.)

Earns money at part-time job (that is, at least 10 hours a week) for 2 1 0
39 1 year. DK ?
Scoring Tip: Do not mark 1. N/O

Attempts to improve job performance after receiving constructive 2 1 0

criticism from supervisor.
40 DK ?
Scoring Tip: You may mark ‘N/O’ for No Opportunity if the
N/O
individual has not held a job.
Manages own money (for example, pays most or all own expenses,
41 2 1 0 DK ?
uses checks or money orders for purchases as needed, etc.)
2 1 0
Has held full time job for 1 year.
42 DK ?
Scoring Tip: Do not mark 1. N/O

43 Budgets for monthly expenses (for example, utilities, rent, etc.). 2 1 0 DK ?

Applies for and uses personal credit card responsibility (for

44 2 1 0 DK ?
example, does not exceed credit limit, pays on time, etc.)

Social Skills and Relationships

Response Options: 2 = Usually, 1 = Sometimes or Partially, 0 = Never, DK = Don’t Know

Circle “?”
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Ages 1 Look at face of parents or caregivers. 2 1 0 DK ?
0-4
 Watches (that is, follows with eyes) someone moving by crib or bed for
2 2 1 0 DK ?
5 seconds or more.

3 Shows two or more emotions (for example, laughs, cries, screams etc.) 2 1 0 DK ?

4 Smiles or makes sounds when approached by a familiar person. 2 1 0 DK ?

Makes or tries to make social contact (for example, smiles, makes

5 2 1 0 DK ?
noises etc.)

6 Reaches for familiar person when person holds out arms to his or her. 2 1 0 DK ?
Shows preference for certain people or object (for example, smiles,
7 2 1 0 DK ?
reaches for or moves toward person or object, etc.)
Shows affection to familiar persons (for example, touches, hugs, kisses,
8 2 1 0 DK ?
cuddles, etc.)
Imitates or tries to imitate parent’s or caregiver’s facial expressions
9 2 1 0 DK ?
(for example, smiles, frowns, etc.)

Moves about looking for parent or caregiver or another familiar person

10 2 1 0 DK ?
nearby.

Shows interest in children with the same age, other than brothers or
11 2 1 0 DK ?
sisters (for example, watches them, smiles at them, etc.)
Start
Imitates simple movements (for example, claps hands, waves good-
Ages 12 2 1 0 DK ?
5-15 bye, etc.)
Uses actions to show happiness or concern for others (for example,
13 2 1 0 DK ?
hugs, pats arm, hold hands, etc.)
Shows desire to please others (for example, shares a snack or toy, tries
14 2 1 0 DK ?
to help even if not capable, etc.)
Demonstrates friendship seeking behavior with others the same age
15 (for example, says, ‘Do you want to play?’ or takes another child by the 2 1 0 DK ?
hand, etc.
Imitates relatively complex actions as they are being performed by
16 another person (for example, shaving, putting on makeup, hammering 2 1 0 DK ?
nails, etc.)

Answers when familiar adults make small talk (for example, if asked,
17 ‘How are you?’ says, ‘I’m fine’; if told, ‘You look nice.’ Says ‘Thank you’ 2 1 0 DK ?
etc.
Repeats phrases heard spoken before by an adult (for example,
18 2 1 0 DK ?
‘Honey, I’m home’; ‘No dessert until you clean your plate.’
Uses words to express own emotions (for example, ‘I’m happy’; ‘I’m
19 2 1 0 DK ?
scared’ etc.)
 Has best friend or shows preference for certain friends (of either sex)
20 2 1 0 DK ?
over others.
Imitates relatively complex actions several hours after watching
21 someone else perform them (for example, shaving, putting on 2 1 0 DK ?
makeup, hammering nails, etc.)
Start
Uses words to express happiness or concern for others (for example,
Ages 22 2 1 0 DK ?
16+ says, ‘Yeah! You won’; ‘Are you all right?’ etc.)
Acts when another person needs a helping hand (for example, holds
23 2 1 0 DK ?
door open, picks up dropped items, etc.)
Recognizes the likes and dislikes of others (for example, says, ‘Chow
24 2 1 0 DK ?
likes soccer’, ‘Susie doesn’t eat pizza’. Etc.)
Shows same level of emotion as others around him or her (for
25 2 1 0 DK ?
example, does not downplay or overdramatize a situation etc.)

Keeps comfortable distance between self and others in social

26 situations (for example, does not get too close to another person 2 1 0 DK ?
when talking, etc.)

Talks with others about shared interests (for example, sports, TV

27 2 1 0 DK ?
shows, summer plans, etc.)

Starts small talk when meets people he or she knows (for example,
28 2 1 0 DK ?
says, ‘How are you?’ ‘What’s up?’ etc.

29 Meets with friend’s regularly. 2 1 0 DK ?

Chooses not to say embarrassing or mean things or ask rude questions

30 2 1 0 DK ?
in public.
Places reasonable demand on friendship (for example, does not expect
31 2 1 0 DK ?
to be a person’s only friend or to have the friend always available, etc.)

Understands that others do not know his or her thoughts unless he or

32 2 1 0 DK ?
she says them.

33 Is careful when talking about personal things. 2 1 0 DK ?

Cooperates with others to plan or be part of an activity (for example, a
34 2 1 0 DK ?
birthday party, sports event, etc.)
Demonstrates understanding of hints or indirect cues in conversation
35 (for example, knows that ‘yawns’ may mean ‘I’m bored’, or a quick 2 1 0 DK ?
change of subject may mean, ‘I don’t want to talk about that’ etc.

36 Goes on group dates. 2 1 0 DK ?

37 Goes on single dates. 2 1 0 DK ?

 Circle “?”
If you
have a
Question
Start
Ages 1 Changes easily from one at-home activity to another. 2 1 0 DK ?
1+
2 Says ‘thank you’ when giving something. 2 1 0 DK ?
Changes behavior depending on how well he or she knows another
3 person (for example, acts differently with family member than with 2 1 0 DK ?
stranger etc.)
4 Chews with mouth closed, 2 1 0 DK ?

5 Says ‘please’ when asking for something. 2 1 0 DK ?

Ends conversations appropriately (for example, says ‘Good-bye’, ‘See

6 2 1 0 DK ?
you later’ etc.)

7 Cleans or wipes face and hands during and/or after meals. 2 1 0 DK ?

Responds appropriately to reasonable changes in routine (for example,

8 2 1 0 DK ?
refrains from complaining etc.)

Says that he or she is sorry for unintended mistakes (for example,

9 2 1 0 DK ?
bumping into someone etc.)

10 Chooses not to taunt, tease or bully. 2 1 0 DK ?

Acts appropriately when introduced to strangers (for example, nods,

11 2 1 0 DK ?
smiles, shakes hands, greets them etc.)

Changes voice level depending on location or situation (for example, in

12 2 1 0 DK ?
a library, during a movie or play etc.)

13 Says he or she is sorry after hurting another’s feelings. 2 1 0 DK ?

14 Refrains from talking with food in mouth. 2 1 0 DK ?

15 Talks with others without interrupting or being rude. 2 1 0 DK ?

16 Accepts helpful suggestions or solutions from others. 2 1 0 DK ?

Controls anger or hurt feelings when plans change for reason (s) that
17 2 1 0 DK ?
cannot be helped (for example, bad weather, car trouble, etc.).

18 Keeps secrets or confidences for longer than one day. 2 1 0 DK ?

 Says he or she is sorry after making unintentional mistakes or errors in
19 judgment (for example, when unintentionally leaving someone out of 2 1 0 DK ?
a game, etc.).

Shows understanding that gentle teasing with family and friends can
20 2 1 0 DK ?
be a form of humor or affection.
Tells parents or caregiver about his or her plans (for example, what
21 2 1 0 DK ?
time he or she is leaving or returning, where he or she is going, etc.).
Chooses to avoid dangerous or risky activities (for example, jumping
22 2 1 0 DK ?
off high places, picking up a hitchhiker, driving recklessly, etc.).

Controls anger or hurt feelings when he or she does not get his or her
23 way (for example, when not allowed to watch television or attend a 2 1 0 DK ?
party, when suggestion is rejected by friend or supervisor etc.)

Follows through with arrangements if promises to meet someone,

24 2 1 0 DK ?
meets that person etc.

Stops or stays away from relationships or situations that are hurtful or

25 dangerous (for example, being bullied or made fun of, being taken 2 1 0 DK ?
advantage of, sexually or financially etc.)

Controls anger or hurt feelings due to constructive criticism (for

26 example, correction of misbehavior, discussion of test score or grade, 2 1 0 DK ?
performance review etc.)

27 Keeps secrets or confidences for as long as needed. 2 1 0 DK ?

Thinks about what could happen before making decisions (for
28 example, refrains from acting impulsively, thinks about important 2 1 0 DK ?
information etc.)
Is aware of potential danger and uses caution when encountering risky
29 social situations for example, binge drinking, parties, internet chat 2 1 0 DK ?
rooms, personal ads etc.
Shows respect for co-workers for example, does not distract or
30 2 1 0 DK ?
interrupt others who are working, is on time for meetings etc.

Playing and Leisure Time

Response Options: 2 = Usually, 1 = Sometimes or Partially, 0 = Never, DK = Don’t Know

Circle “?”
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Start
Responds when parent or caregiver is playful (for example, smiles,
Ages 1 2 1 0 DK ?
0-7 laughs, claps hands, etc.)

Shows interest in where he or she is (for example, looks or moves

2 2 1 0 DK ?
around, touches objects or people, etc.)

Plays simple interaction games with others (for example, peekaboo,

3 2 1 0 DK ?
patty-cake, etc.)

4 Plays near another child, each doing different things. 2 1 0 DK ?

Chooses to play with another children (for example, does not stay on
5 2 1 0 DK ?
edge of a group or avoid others)

6 Plays cooperatively with one or more children up to 5 minutes. 2 1 0 DK ?

7 Plays cooperatively with more than one child for more than 5 minutes. 2 1 0 DK ?

Continues playing with another child while little fussing when parent
8 2 1 0 DK ?
or caregiver leaves.

9 Shares toys or possessions when asked. 2 1 0 DK ?

Start
Ages 10 Plays with others with minimal supervision. 2 1 0 DK ?
8-15
Uses common household objects or other objects for make-believe
11 2 1 0 DK ?
activities (for example, pretends a block is a car, a box is a house etc.)
Protects self by moving away from those who destroy things or cause
12 2 1 0 DK ?
injury (for example, those who bite, hit, throw things, pull hair, etc.)

Plays simple make-believe activities with others (for example, plays

13 2 1 0 DK ?
dress-up, pretends to be superheroes, etc.)

Seeks out others for play or companionship (for example, invites

14 others home, goes to another’s home, plays with others on the 2 1 0 DK ?
playground etc.)

15 Takes turns when asked while playing games or sports. 2 1 0 DK ?

Plays informal, outdoor group games (for example lag, jump rope,
16 2 1 0 DK ?
catch etc.)

17 Shares toys or positions without being asked. 2 1 0 DK ?

Follows rules in simple games (rally race, spelling bees, electronic

18 2 1 0 DK ?
games etc.)

19 Takes turns without being asked. 2 1 0 DK ?

Plays simple card or board game based only on chance (for example,
20 2 1 0 DK ?
go fish, crazy Eights, sorry etc.)
 Goes places with friends during the day with adult supervision (for
21 2 1 0 DK ?
example, to a shopping mall, park, community center etc.)
Start
Asks permission before using objects belonging to or being used by
Ages 22 2 1 0 DK ?
16+ another.
Refrains from entering group when non-verbal cues indicate that he or
23 2 1 0 DK ?
she is not welcome.
Plays simple games that require keeping score (for example, kick ball,
24 2 1 0 DK ?
pickup basketball etc.)

Shows good sportsmanship (that is, follow rules, is not overly

25 aggressive, congratulates another team on winning, and does not get 2 1 0 DK ?
mad when loosing.)

Plays more than one board, card or electronic game requiring skill and
26 2 1 0 DK ?
discussion making (for example, Monopoly, cribbage etc.)

Goes places with friends in evening with adult supervision (for

27 2 1 0 DK ?
example, to a concert, lecture, sporting event, movie, etc.)

Follows rules in complex games or sports (for example, football,

28 2 1 0 DK ?
soccer, volleyball etc.)
Goes places with friends during the day without adult supervision (for
29 2 1 0 DK ?
example, to a shopping mall, park, community center etc.)
Plans fun activities with more than two things to be arranged (for
30 example, a trip to a beach or park that requires planning 2 1 0 DK ?
transportation, food, recreational items etc.)

Goes places with friends in evening without adult supervision (for

31 2 1 0 DK ?
example, to a concert, lecture, sporting event, movie etc.)

Physical Activity
Response Options: 2 = Usually, 1 = Sometimes or Partially, 0 = Never, DK = Don’t Know

Circle “?”
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Start
Holds head erect for at least 15 seconds when held upright in parents
Ages 1 2 1 0 DK ?
0-1 or caregivers’ arms.
Sits supported (for example, in a chair, with pillows etc.) for at least
2 2 1 0 DK ?
one minute.

3 Sits without support for at least one minute. 2 1 0 DK ?

4 Creeps or moves stomach across floor. 2 1 0 DK ?

5 Sits without support for at least 10 minutes. 2 1 0 DK ?

Raises self to sitting position and sits without support for at least 1
6 2 1 0 DK ?
minute.
Crawls at least 5 feet on hands and knees, without stomach touching
7 2 1 0 DK ?
floor.

8 Pulls self to standing position. 2 1 0 DK ?

9 Crawls upstairs. 2 1 0 DK ?

10 Takes at least 2 steps. 2 1 0 DK ?

11 Stands alone for 1 to 3 minutes. 2 1 0 DK ?

12 Rolls ball while sitting. 2 1 0 DK ?

13 Climbs on and off low objects for example, chair, step stool, slide etc. 2 1 0 DK ?

14 Crawls downstairs. 2 1 0 DK ?

15 Stands for at least 5 minutes. 2 1 0 DK ?

Start
Ages 16 Walks across room; maybe unsteady and fall occasionally. 2 1 0 DK ?
2-4

17 Throws ball. 2 1 0 DK ?

18 Walks to get around; does not need to hold on to anything. 2 1 0 DK ?

19 Climbs on and off adult sized chair. 2 1 0 DK ?

20 Runs without falling; maybe awkward and uncoordinated. 2 1 0 DK ?

21 Walks upstairs, putting both feet on each step; may use railing. 2 1 0 DK ?

22 Kicks ball. 2 1 0 DK ?

23 Runs smoothly without falling. 2 1 0 DK ?

 Walks downstairs, facing forward, putting both feet on each step; may
24 2 1 0 DK ?
use railing.

25 Jumps with both feet off floor. 2 1 0 DK ?

Start
Ages 26 Throws ball of any size in specific direction. 2 1 0 DK ?
5-6

Catches beach ball-sized ball with both hands from distance of 2 or 3

27 2 1 0 DK ?
feet.

28 Walks upstairs, alternating feet; may use railing. 2 1 0 DK ?

Pedals tricycle or other 3 wheeled toy for at least 6 feet.

Scoring Tip: You may mark ‘N/O’ for No Opportunity if the individual does 2 1 0
29 not have a tricycle or 3 wheeled toys. However, if the individual has such a DK ?
vehicle but does not ride it for any reason, including parent or caregiver does
not think he or she is ready, mark 0. N/O

30 Jumps or hops forward at least 3 times. 2 1 0 DK ?

Hops on 1 foot at least once without falling; may hold onto something
31 2 1 0 DK ?
for balance.
Climbs on and off high objects (for example, jungle gum, 4-foot slide
32 2 1 0 DK ?
ladder, etc.)

33 Walks down stairs, alternating feet, may use railing. 2 1 0 DK ?

34 Runs smoothly, with changes in speed and direction. 2 1 0 DK ?

Rides bicycle with training wheels for at least 10 feet.

Scoring Tip: You may mark ‘N/O’ for No Opportunity if the individual does 2 1 0
35 not have a bicycle. However, if the individual has a bike but does not ride it DK ?
for any reason, including parent or caregiver does not think he or she is
N/O
ready, mark ‘0’.

Catches beach ball-sized ball (for at least 6 feet away) with both
36 2 1 0 DK ?
hands.

37 Hops forward on one foot with ease. 2 1 0 DK ?

38 Skips at least 5 feet. 2 1 0 DK ?

Catches tennis or base-ball sized ball (from at least 10 feet away),
39 2 1 0 DK ?
moving to catch it if necessary.
Rides bicycle with no training wheels without falling.
40 Scoring Tip: You may mark ‘N/O’ for No Opportunity if the individual does 2 1 0 DK ?
not have a bicycle. However, if the individual has a bike but does not use it
 for any reason, including parent or caregiver does not think he or she is
N/O
ready, mark ‘0’.

Circle “?”
If you
have a
Question
Start
Age 1 Reaches for toy or objects. 2 1 0 DK ?
0-4

Picks up small objects (no larger than 2 inches on any side) may use
2 2 1 0 DK ?
both hands.

3 Moves object from one hand to the other. 2 1 0 DK ?

4 Squeezes squeaky toy or object. 2 1 0 DK ?

5 Picks up small objects with thumb or fingers. 2 1 0 DK ?

6 Removes object (for example, a block or clothespin) from a container. 2 1 0 DK ?

7 Puts object (for example, a block or clothespin) into a container. 2 1 0 DK ?

8 Turns pages of board, cloth or paper book, one at a time. 2 1 0 DK ?

Stacks at least four small blocks or other small objects; stack must not
9 2 1 0 DK ?
fall.

10 Opens doors by turning doorknobs. 2 1 0 DK ?

Start
Ages 11 Unwraps small objects (for example, gum or candy). 2 1 0 DK ?
5-6

12 Completes simple puzzle of at least two pieces or shapes. 2 1 0 DK ?

13 Turns book or magazine pages one by one. 2 1 0 DK ?

Uses twisting hand-wrist motion (for example, winds up toy,

14 2 1 0 DK ?
screws/unscrews lid of jar etc.)

15 Holds pencil in proper position (not with fist) for writing or drawing. 2 1 0 DK ?

16 Colors simple shapes, may color outside lines. 2 1 0 DK ?

 Builds three-dimensional structures (for example, a house, bridge,
17 2 1 0 DK ?
vehicle etc.)

18 Opens and closes scissors with one hand. 2 1 0 DK ?

Glues or pastes two or more pieces together (for example, for art or
19 2 1 0 DK ?
science projects, etc.)
Uses tape to hold things together (for example, torn page, art project,
20 2 1 0 DK ?
etc.)
Draws more than one recognizable form (for example, person, house,
tree etc.) 2 1 0
Scoring Tip: Mark a ‘2’ if the individual draws two or more recognizable DK ?
21 forms; mark ‘1’ if the individual draws one form; mark a ‘0’ if the individual
does not draw any recognizable forms. N/O

22 Makes recognizable letters or numbers. 2 1 0 DK ?

23 Draws circle free hand while looking at example. 2 1 0 DK ?

24 Uses scissors to cut across paper along a straight line. 2 1 0 DK ?

25 Colors simple shapes; colors inside the lines. 2 1 0 DK ?

26 Cuts out simple shapes for example, circles, squares, rectangles etc. 2 1 0 DK ?

27 Uses eraser without tearing paper. 2 1 0 DK ?

28 Draws square free hand while looking at example. 2 1 0 DK ?

29 Draws triangle free hand while looking at example. 2 1 0 DK ?

30 Ties knot. 2 1 0 DK ?

31 Draws straight line using a ruler or straightedge. 2 1 0 DK ?

Unlocks dead-bolt, key, or combination locks that require twisting. 2 1 0

32 Scoring Tip: You may mark ‘N/O’ for No Opportunity if there are no dead- DK ?
bolt, key or combination locks in the house.
N/O

Cuts out complex shapes (for example, stars, animals, alphabets,

33 2 1 0 DK ?
letters etc.)
Uses keyboard, typewriter or touch screen to type name or short
words; may look at keys.
34 2 1 0 DK ?
Scoring tip: You may mark ‘N/O’ for No Opportunity if there is no
computer in the home.
 35 Ties secure bow. 2 1 0 DK ?

Uses a keyboard to type up to 10 lines; may look at the keys. 2 1 0

36 Scoring Tip: You may mark ‘N/O’ for No Opportunity if there is no DK ?
computer in the home. N/O

Problem Behavior Part 1

Response Options: 2 = Usually, 1 = Sometimes or Partially, 0 = Never

Start
Ages 1 Is overly dependent (that is clings to caregiver, teachers, brother, or sister). 0 1 2
3+

2 Avoids others and prefers to be alone. 0 1 2

Has eating difficulties (eats too fast or too slow, hoards food, overeats, refuses
3 0 1 2
to eat, etc.).

Has sleep difficulties (for example, sleepwalks has frequent nightmares, sleeps
4 0 1 2
significantly more or less than typical for his or her age).
Refuses to go to school or work because of fear, feelings of rejection or
5 0 1 2
isolation, etc.).

6 Is overly anxious or nervous. 0 1 2

7 Cries or laughs too easily. 0 1 2

Has poor eye contact (that is, does not look at or face others when speaking or
8 0 1 2
spoken to).

9 Is sad for no clear reason. 0 1 2

10 Avoids social interaction. 0 1 2

11 Lacks energy or interest in life. 0 1 2

Start
Ages 1 Is impulsive (that is, acts without thinking). 0 1 2
3+

2 Has temper tantrums. 0 1 2

3 Intentionally disobeys and defies those in authority. 0 1 2

4 Taunts, teases or bullies. 0 1 2

5 Is inconsiderate or insensitive to others 0 1 2

6 Lies, cheats or steals. 0 1 2

7 Is physically aggressive (for example, hits, kicks, bites, etc.). 0 1 2

8 Is stubborn or sullen. 0 1 2

Says embarrassing things or asks embarrassing questions in public (for example

9 0 1 2
“You’re fat” or “What that big red thing on your nose?”).

10 Behaves inappropriately at the urging of others 0 1 2

Start
Ages 1 Sucks thumb and finger. 0 1 2
3+

2 Wets bed or must wear diapers at night 0 1 2

Acts overly familiar with stranger (for example, holds hands, hugs, sits on lap,
3 0 1 2
etc.).
4 Bites fingernails 0 1 2

5 Has tics (that is involuntary blinking, twitching, head shaking, etc.). 0 1 2

 6 Grinds teeth during the day or night 0 1 2

7 Has a hard time paying attention 0 1 2

8 Is more active or restless than others of same age 0 1 2

Uses school or work properly (for example, telephone, internet access

9 0 1 2
office supplies, etc.) for unapproved personal purposes.

10 Swears 0 1 2

11 Runs away (that is, is missing for 24 hours or longer). 0 1 2

12 Is truant from school or work. 0 1 2

13 Ignores or doesn’t pay attention to others around him or her. 0 1 2

14 Uses money or gifts to “buy” affection. 0 1 2

15 Uses alcohol or illegal drugs during the school or work day. 0 1 2

Problem Behavior Part 2

Response Options: 2 = Usually, 1 = Sometimes or Partially, 0 = Never, M = Moderate, S = Severe

Start
Engages in appropriate sexual behavior (for example, exposes self,
Ages 1 0 1 2 M S
3+ masturbates in public, makes improper sexual advances, etc.).
Is obsessed with objects or activities (for example, constantly
2 repeats words, or phrases, is preoccupied with mechanical objects, 0 1 2 M S
etc.).
 Express thoughts that do not make sense (for example talks about
3 0 1 2 M S
hearing voices, seems delusional, etc.).

Has strange habits (for example, make repetitive noises

4 0 1 2 M S
odd hand movements, etc.).
Constantly prefer objects to people. (for example, pays more
5 0 1 2 M S
attention to objects than the people, etc.).

Display behaviors that cause injury to self (for example bangs

6 0 1 2 M S
head, hits or bites self, tears at skin, etc.).

7 Destroys own or others possession on purpose 0 1 2 M S

Uses bizarre speech (for example has conversation with self in

8 public, speaks in phrases or sentences that have no meaning, 0 1 2 M S
repeats same word or phrase over and over, etc.).
Is unaware of what is happening around him or her (for example
9 0 1 2 M S
seems to be in a “fog”; stares blankly)

10 Rocks back and forth repeatedly. 0 1 2 M S

11 Is usually fearful of ordinary sounds, objects, or situations. 0 1 2 M S

12 Remembers odd information in details years later. 0 1 2 M S

Is unable to complete a normal school or work day because of

13 0 1 2 M S
chronic pain or fatigue.

Is unable to completes a normal school or work day because of

14 0 1 2 M S
psychological symptoms.

VINELAND-II PAIRWISE COMPARISON

Freq.of
Difference
Standard Stat.Sign (Extreme
Score\ Level 16, 10.5 or
Domain Comparisons Standard <, > Standard (.05 or.01)
score score Differences 1%)
or,= Table D.1
Table D.2
Daily living skills
Communication
Socialization
Communication
Socialization
Daily living skills
 Motor skills
Communication
Motor skills
Socialization
Motor skills
Daily living skills
Freq. of
Difference
(Extreme
16, 10,5 or
Stat.Sign. 1%)
v=Scale
Level Table D.4
v=Scale <, > v=Scale Score (.05 or.01)
Subdomain Comparisons Score or,= Score Difference Table D.3 or
D.5

Communication
Receptive Expressive

Receptive Written

Expressive Written

Daily Living Skills

Personal Domestic

Personal Community

Domestic Community

Socialization
Interpersonal relationship Play and leisure time

Interpersonal relationship Coping skills

Individual______________________________ Date______ Age_________ Form:____Survey interview

Parent/Caregiver Rating

VINELAND-II SCORE SUMMARY

STRENTHS AND
SUBDOMAIN and DOMAIN SCORES
Domain
WEAKNESS
v=Scale __% %ile Score
Standard Age Stanine
SUBDOMAIN/ Raw Standard Conf. Rank Adaptive
Score Equivalent Table C.3 Minus
DOMAIN scores Score Interval Table Level
Table Table C.3
Table C.5 Median*
Table B.1 Table C.4
 B.2 C.1/C.2

Receptive _______
Expressive
_______
Written
_______
Communication Sum:_________
_______

Personal _______

Domestic _______

Community _______

Daily living skills Sum:_________ _______

Interpersonal _______
Relationships
Play and leisure _______
time
_______
Coping skills
_______
Socialization Sum:_________
_______

Gross _______

Fine _______

Motor Skills Sum:_________ _______

 For instructions on how
to determine the median
score. See chapter 3 of
Sum of Domain =
Standard Score Vineland-II survey
__% %ile Adaptive Stanine forms manual.
Standard Conf Rank Level C.3
Score Table C.3 Table
Table B.2
Interval
C.4 Domain
Table
Strengths/Weakness
C.1/C.2

S=Standard Score-
Median >
W= Standard Score-
Median <=10
Subdomain
Strengths/Weakness
S= v-scale Score –
Median>=2
W=v-scale Score-
Median<=2