"Student Reinforcement Survey Template - South Bend Community School Corporation"

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Download "Student Reinforcement Survey Template - South Bend Community School Corporation"

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South Bend Community School Corporation
Special Education Department
 
Student Reinforcement Survey
Student:
School:
Grade:
Date of Birth:
Age :
Interviewer:
Date Completed:
Directions: To complete this survey, it is recommended that each question be read to the student in an informal
manner. While you should guard against pressuring a student to complete each statement, please be
sure to follow-up or clarify any vague responses.
For younger children, you may want to consider placing each item on cards and use them to play a game
(using a generic game board). The items can be made less threatening in a game-like format because you
will be completing the statements along with the student.
Your primary goal of this survey is to determine those reinforcers that have the greatest potential for use in
a plan for behavior support.
Sentence Completion
1.
My favorite adult at school is:
The things I like to do with this adult are:
2
My best friend at school is:
Some things I like to do with my best friend at school are:
3.
Some other friends I have at school are:
Some things I like to do with them are:
4.
When I do well in school, a person I’d like to know about it is:
5.
When I do well in school, I wish my teacher would:
6.
At school, I’d like to spend more time with:
Some things I’d like to do with this person are:
7.
One thing I’d really like to do more in school is:
8.
When I have free time at school I like to:
9.
I feel great in school when:
10. The person who likes me best at school is:
I think this person likes me because:
11. I will do almost anything to keep from:
12. The kind of punishment at school that I hate most is:
13. I sure get mad at school when I can’t:
14. The thing that upsets my teacher the most is:
15. The thing that upsets me the most is:
8/6/10
South Bend Community School Corporation
Special Education Department
 
Student Reinforcement Survey
Student:
School:
Grade:
Date of Birth:
Age :
Interviewer:
Date Completed:
Directions: To complete this survey, it is recommended that each question be read to the student in an informal
manner. While you should guard against pressuring a student to complete each statement, please be
sure to follow-up or clarify any vague responses.
For younger children, you may want to consider placing each item on cards and use them to play a game
(using a generic game board). The items can be made less threatening in a game-like format because you
will be completing the statements along with the student.
Your primary goal of this survey is to determine those reinforcers that have the greatest potential for use in
a plan for behavior support.
Sentence Completion
1.
My favorite adult at school is:
The things I like to do with this adult are:
2
My best friend at school is:
Some things I like to do with my best friend at school are:
3.
Some other friends I have at school are:
Some things I like to do with them are:
4.
When I do well in school, a person I’d like to know about it is:
5.
When I do well in school, I wish my teacher would:
6.
At school, I’d like to spend more time with:
Some things I’d like to do with this person are:
7.
One thing I’d really like to do more in school is:
8.
When I have free time at school I like to:
9.
I feel great in school when:
10. The person who likes me best at school is:
I think this person likes me because:
11. I will do almost anything to keep from:
12. The kind of punishment at school that I hate most is:
13. I sure get mad at school when I can’t:
14. The thing that upsets my teacher the most is:
15. The thing that upsets me the most is:
8/6/10
 
16. Some things I like are (check all that apply):
Favorite Edible Reinforcers
Favorite Tangible Items
o
candy (specify
)
o
stuffed animals
o
fruit (specify
)
o
pencils, pens, crayons
drinks (specify
)
paper (specify
)
o
o
o
cereal (specify
)
o
trucks, tractors
o
snacks (specify
)
o
sports equipment (specify
)
o
nuts (specify
)
o
toys (specify
)
o
vegetables (specify
)
o
books (specify
)
o
other (specify
)
o
puzzles
Academic Reinforcers
Social Reinforcers
o
going to library
o
teaching things to other people
having good work displayed
being the teacher’s helper
o
o
o
getting good grades
o
spending time with my friends
o
having parents praise good school work
o
spending time with the teacher
o
giving reports
o
spending time with the principal
o
making projects
o
spending time with
o
completing creative writing projects
o
having class parties
o
earning teacher praise
o
working with my friends in class
o
helping grade papers
o
being a tutor
o
getting a good note home
o
being a leader in the class
o
earning stickers, points, etc
o
other (specify
)
o
other (specify
)
7/18/16
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