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Reinforcer SurveySecondary LevelName of Student: ____________Date: __________ D of B ______________________ Age: _________Evaluation was by: ______________ Other (name): ___________________Note: Write NA beside a question if it is Not Applicable. Check off only those things the student loves to eat most of the time. Can use ideas for food coupons/discounts in community FORMTEXT ?????ice cream FORMTEXT ?????candy FORMTEXT ?????potato chips FORMTEXT ?????cookies FORMTEXT ?????other FORMTEXT ?????fruits FORMTEXT ?????cold cereal FORMTEXT ?????hot cereals FORMTEXT ?????cheese (please list): FORMTEXT ?????food coupon FORMTEXT ?????pretzels FORMTEXT ?????sandwiches FORMTEXT ?????milk FORMTEXT ?????soda FORMTEXT ?????pastry FORMTEXT ?????water FORMTEXT ?????pudding FORMTEXT ?????salads FORMTEXT ?????pasta FORMTEXT ?????hamburgers FORMTEXT ?????fries FORMTEXT ?????nuts FORMTEXT ?????vegetables FORMTEXT ?????steak FORMTEXT ?????eggs FORMTEXT ?????rice FORMTEXT ?????hot dogs FORMTEXT ?????fruit juice FORMTEXT ?????popcorn What are the student’s three favorite foods? 1. ________________________________________ 2. _____________________________________3. ________________________________________ How much does the student like: Loves it Likes it Doesn’tNo opportunity/ like it unable to do Playing Games FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? Looking at magazines (kind?) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? Drawing pictures/painting FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Building Models FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Listening to music FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Watching movies FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Special Interests (name it) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Historical facts FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Sport activities FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Tracing designs FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Their pet(s) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Describe: _______________________________________________ Imitating the physical actions of others FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????How much does the student like: Loves it Likes it Doesn’tNo opportunity/ like it unable to doWalking the halls FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? Looking up facts FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Learn a foreign language FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Do Math problems FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? Puzzles FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Hides FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? Water play/swimming FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? Good Hygiene FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? Interacting other peers FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? Activities with the family FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????A trip to the zoo FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????A trip to the library FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Visiting a park FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Visiting the dentist FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Visiting the doctor FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Camping FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Playing outside FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Watching television FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Snacking on foods FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? Going shopping FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Going to movies FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Being read or told stories FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Reading to others FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Dance FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????High Fives FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Clubs/Organizations FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Being praised FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????How much does the student like: Loves it Likes it Doesn’tNo opportunity/ like it unable to doBeing around the family FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Being around other peers FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? Being alone FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Receiving gold stars, points,or stickers FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Getting letters/notes/cards FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Reading books FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? Listening to the radio FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Riding a bicycle FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Swinging FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Playing on a computer FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Other Technology FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Listening to music FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Playing an instrument FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Being with parents FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????What things bother or disturb the student the most? ______________________________________________________________________________________________________________________________________What does the student like to do the most by himself? __________________________________________________________________________________________What does the student like to do the most with other students his age? __________________________________________________________________________________________________________________________ What does the student like to do the most with the family? _______________________________________________________________________________________________________________________________What things does the student like to talk about most of the time? _____________________________________________________________________________________________________________List any talents or skills the student has towards which people respond warmly:_____________________________________________________________________________________________________________Any other information you feel might be important: __ _________________________________________________________________________________________________________________________________ ................
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