Goal Attainment Scale Form

Goal Attainment Scale

GOAL ATTAINMENT SCALE FORM

Person(s) completing the form: John Doe and Team Date: 8-29-08 State: FPG State 1, Site 3 Model Site: Student (initials): Student DOB:

Level Goal 1: Goal 2: Goal 3: of Identify need to reduce Follow schedules of leisure Initiate verbal interaction with Attainment anxiety in classroom activities independently peers to join an activity settings Much less than UU always requires visual teacher UU engages in internet use for every UU exhibits anxious behavior when near a expected prompts to leave the area when leisure break, ignoring a schedule of peer, joining only when visually prompted -2 anxious and to use a visual story to daily leisure activity choices. in 5 of 10 opportunities. regain composure. Somewhat less UU independently goes to UU complies with allowed internet use When visually prompted, UU will always than expected appropriate area in the classroom on the leisure activity schedule on 4 join peer in desired activity. -1 when anxious and uses a visual of 10 days and chooses other leisure story to regain composure 50% of activities from his schedule. the time during a two-week interval. Expected level of UU independently goes to an UU complies with allowed internet use UU, verbally, will initiate interaction with outcome appropriate area at school when on the leisure activity schedule on 8 peers to join an activity in 4 of 10 0 anxious and uses a visual story to of 10 days and chooses other leisure opportunities without prompting. regain composure 90% of the time activities from his schedule. during a two-week interval Somewhat more UU verbally states “I need a break” UU complies with allowed internet use UU, verbally, will initiate interaction with than expected when anxious without prompts and at home on 5 of 10 days. peers to join an activity in 8 of 10 +1 takes a walk to look at his visual opportunities without prompting. story, returning to scheduled activity without disruption 3 times a week for 2 months. Much more than UU uses strategies (stress ball or UU creates and follows a weekly UU will invite a peer to play a computer expected fidgit) to reduce anxiety in the internet use schedule at school and at game during computer time at school +2 classroom and stay focused on home with 80% fidelity for 2 months. without prompts in 2 of 4 opportunities.. scheduled activity 3 times a week for 2 months.

National Professional Development Center on ASD 1 8-29-08