Nunavik Adaptive Behavior Scale – Experimental version
!
"
Teacher's Evaluation Form
#
$ % &
FIRST AND LAST
NAME:
MOBILITY
IMPAIRMENT:
SENSORY
IMPAIRMENT :
OTHER
DISABILITY
OR DIFFICULTY :
DATE OF BIRTH :
GENDER :
Day
Month
Year
Age :
Years
Months
Circle : F or M
GRADE :
%
FIRST AND LAST NAME:
NAME OF SCHOOL :
DATE OF EVALUATION :
Day
Month
Year
This questionnaire may only be reproduced for correction purposes, either by transmitting
data to the LMCA or through the online correction platform
Developed by the Laboratoire de mesure du comportement adaptatif (LMCA)
in collaboration with the Nunavik Regional Board of Health and Social Services (NRBHSS)
2007-06
Demographic and clinical information
Please answer these questions before you start answering the questionnaire.
Information on the child evaluated
1. In what type of environment is the evaluated child living in (e.g. natural family, foster home,
supervised residence)?________________________________________________________________
2. a) Is there a medical diagnosis of the child?
No
Yes, which one_______________________
I don’t know
b) Does it impact her/his behaviors to your opinion?
No
Yes, I’m ______% sure
I don’t know
3. Ethnic origin of the child evaluated? Father:________________ Mother:_____________________
4. Language spoken at home (of the child evaluated):_______________________________________
5. When did the difficulties of the child appear to your knowledge?____________
6. Are there previous evaluations of deficit in intelligence?
No
Yes
I don’t know
7. Can you name other persons that could give information on the usual behaviors of the child?
_________________________________________________________________________________
Information on the evaluator
1. Since when do you know the child evaluated? Years:______Months:______
2. How many hours per week are you in contact with the child evaluated?_______________________
3. In which environments have you observed the child?
(e.g. home, school, outside, etc.)______________________________________________________
Nunavik Adaptive Behavior Scale – School version (NABS – SV)
2
Procedure for completing the questionnaire
Cover page of the NABS-SV
All questions on the cover page must be answered including AGE.
Scoring procedure
0
DOES NOT DO IT
No…never…does not do it…is not able to...
You must give persons who do not exhibit the behavior the score “DOES NOT DO IT”, even
if you believe they have the ability to do it.
1
DOES IT, BUT...
Yes, but...upon request...must remind her/him...sometimes...rarely…does it more or less...does
it but not finish it... irregularly…does it but...
The score “DOES IT, BUT” is given to situations that are neither a definite “DOES IT” nor a
“DOES NOT DO IT”.
2
DOES IT
Often...skillfully...regularly...yes...on a regular basis...without assistance...on her/his own
initiative...done well...done properly...most of the time...
The score “DOES IT” is also given for activities no longer performed because the child has
outgrown the need to perform them. For example, when a child “Relates experiences in a
coherent fashion”(item 3), it is assumed that she/he has already “Uses a few words or formal
signs to obtain a desired object”. That item is thus given score 2.
D
DISABILITY
Score D (Disability) means that a physical or sensorial disability prevents the child from
exhibiting the behavior.
NO
NOT OBSERVABLE
Score NO (Not Observable) is given only when the conditions of the setting prevent one from
observing the child'
s behavior, thereby making an evaluation of her/his performance
impossible. Score “NO” is also given if it is assumed that the child could exhibit the behavior
that we ourselves are not in the position to observe. For example, it could be difficult for
teachers to evaluate certain items from the domain “Leisure”. This score should be used
OCCASIONALLY.
Nunavik Adaptive Behavior Scale – School version (NABS – SV)
3
Scoring adaptive behavior
1. The scale evaluates performance and not potential. Score 0 is thus given for items which the
child does not perform by her/himself even if it seems she/he could perform them if she/he
wanted to.
2. Even if the questionnaire evaluates the child'
s performance, it is important to consider that
certain items must be seen from a developmental perspective. As thus it is possible that a child
has already exhibited a certain behavior, but that she/he has now passed that stage and no longer
exhibits it. For example, if a child talks, it is assumed that she/he has already “Use(d) a few
words or formal signs to obtain a desired object”. That item is thus given score 2.
This applies in particular to the domain “Communication”.
3. Children who express themselves with sign language or a communication board should receive
the points for items involving verbal expression.
4. It is very important to answer all the questions.
5. Items with an asterisk must be considered in mother tongue (French, English or Inuktitut) of
the child. The child should not be penalized for learning a second language.
Examples of the different scores as given to questionnaire items
Score:
2=
“Uses a few words or formal signs to obtain a desired object”(item 3) for a child that
can communicate verbally.
1=
“Raises hand in class to ask to speak” (item 27), if the child must be reminded
regularly.
0=
“Uses a calculator” (item 65), if the child is incapable of exhibiting the behavior or if
the child never exhibits the behavior even if she/he is capable.
NO=
“Does simple multiplications and additions” (item 70), if it is not one of the program
objectives (i.e. if there is no occasion for observing it) and even if it is assumed that the
child could exhibit the behavior if given the possibility.
D=
“Writes three numbers or letters” (item 53), if the child cannot exhibit the behavior
due to a physical or sensorial impairment and does not use another means of
communication (e.g. communication board or computer).
Nunavik Adaptive Behavior Scale – School version (NABS – SV)
4
))$
%
1.
Names five familiar objects (e.g. kamiks, fork) *
2.
Names five indicated parts of a picture * (e.g. -what is this? - the dog's tail)
3.
Uses few words or formal signs to obtain a desired object *
4.
Uses negatives in sentences (e.g. He wasn't there, I'm not happy) *
5.
Constructs sentences containing a subject, verb, and complement *
6.
Uses grammatically correct language despite a few pronunciation errors *
7.
Asks for an explanation when not understanding something *
8.
Uses personal pronouns (I, you, he, we, you, they) *
9.
Relates experiences in coherent fashion *
10. Answers questions about a short story just read to her/him *
11. States own home number on demand
12. Describes an event (e.g. what happened at a sports game, television show) *
13. At times, has long conversations with peers *
14. Writes short notes of at least 5 words *
15. Follows complex explanations or instructions *
16. Writes short letters or e-mails of at least 3 sentences *
17. Makes an oral presentation in front of the class when prepared ahead of time *
'
( %
18. Engages in brief interactions with peers *
19. Shakes hands, greets or waves to familiar people
20. Follows simple instructions (e.g. seats or remains silent on request)
21. Shares personal belongings with classmates (e.g. pencil, book, toy)
22. Uses proper courtesy phrases (e.g. thank you, excuse me, sorry) *
23. Gives information when known to her/him *
24. Participates actively in group activities (upon request)
25. Develops and maintains friendships
* In French, English or Inuktitut
NABS-SV
5
26. Cooperates with friends
27. Raises hand in class to ask to speak
28. Maintains and ends a conversation appropriately *
29. Works easily in team (e.g. gets along with others, respects their opinions and ideas, etc.)
30. Interrupts a person politely when needing to talk (e.g. excuse me, can I talk to you, etc.)
31. Tells the consequences of her/his actions on others (e.g. disrespecting someone will hurt his
feelings)
32. Anticipates the consequences of her/his acts
33. Offers constructive criticism *
*+ $ %
),
34. Indicates verbally or through gestures a preference when given a choice
35. Expresses basic needs (e.g. hunger, thirst) by means other than crying
36. Finds interest in a task or game
37. Identifies tasks she/he likes or does not like doing
38. Asks for help when needed
39. Asks for permission before leaving class
40. Follows the class routine
41. Completes assigned work in class
42. Is attentive in class for most of the day
43. Expresses her/his emotions in an appropriate manner
44. Organizes material required for a task on her/his own
45. Expresses her/his difficulties in an appropriate manner
46. Works in team
47. Continues to try even if facing difficulties
48. Follows a work plan appropriate to age
* In French, English or Inuktitut
NABS-SV
6
-+#
&
& )
.
49. Sorts objects by colour and size
50. Reads own name written on a sheet *
51. Tells the heaviest or the longest between two
52. Flips pages of a book one at a time
53. Writes three numbers or letters *
54. Tells the number of a quantity of objects
55. Tells the four seasons *
56. Writes her/his first name and last name *
57. Follows verbal instructions concerning work to be done *
58. Identifies all the letters of the alphabet *
59. Reads short sentences (about 5 words or more) *
60. Writes short sentences (about 5 words or more) *
61. Writes a short and simple letter *
62. Does simple additions and subtractions
63. Copies information from the blackboard, written documents, and school texts *
64. Adds three items price numbers for a maximum total of $10
65. Uses a calculator
66. Reads children stories *
67. Follows written instructions *
68. Reads information from print media (newspapers, magazines)
69. Uses the dictionary and other reference sources (e.g. books, Internet)
70. Does simple multiplications and divisions
71. Takes notes when teacher gives important explanations
72. Finds a book in the library using the search system
$
73. Listens and participates to kindergarten rhymes and songs
74. Plays alone for at least 10 minutes
* In French, English or Inuktitut
NABS-SV
7
75. Plays with other children for short periods of at least 15 minutes
76. Finishes an activity before starting another one
77. Is attentive for at least 20 minutes at a leisure activity
78. Looks for and finds a game to keep busy on her/his own
79. Cooperates when playing (e.g. takes turn, makes a pass)
80. Follows rules of group games (e.g. waits for her/his turn)
81. Does arts-and-crafts
82. Uses scissors properly
83. Explains game rules to others *
+ $%&
%
%
84. Can drink water from stream with cupped hands
85. Eats raw fish or meat with her/his hands and tears it with teeth
86. Fishes with a fishing hook (aulasautik) on ice
87. Gets fresh water with a container on an excursion
88. Picks appropriate berries (e.g.cloudberries)
89. Makes a hole in ice with a hatchet
90. Drives a snowmobile to get around
91. Drives a four-wheeler to get around
92. On excursions, wipes her/himself with appropriate materials (leaves, Kleenex, toilet paper)
93. Shoots fixed target with gun
94. Safely lights up charcoal or camping gas stove
95. Fishes without necessarily having all the skills
96. Sets up a tent (tupiq)
97. Starts a fire with hand-picked twigs and other materials
98. Occasionally catches small animals with traps
99. Follows a leader at excursions
100. Melts snow to drink or cook
101. In blizzard conditions, takes shelter for protection (e.g. uses qamutik to protect her/himself)
102. Goes out of sight of the village and is able to come back
* In French, English or Inuktitut
NABS-SV
8
103. Uses a kayak for short excursions
104. Cuts open a fish with knife and takes out guts
105. Cooks food outside on a campfire or other
106. Find her/his way using visual features of the landscape
107. Chooses the right lure to catch fish
108. Catches fish regularly on the side of river or lake (without ice)
109. Cuts up game for eating
110. Drives a motorboat to go fishing or hunting
111. Organizes excursions with small group of friends
112. Regularly traps small animals with knots (snares)
113. Regularly catches small game with gun
Comments:________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Information on the questionnaire’s administration (to be completed by the teacher)
1. I’m______% confident that my estimate reflects the behaviors of the child.
2. I’m______% confident that the performance of the child reflects her/his capacities.
3. It was easy for me to answer those questions about the child evaluated?
yes
no
more or less
4. It took me approximately _____ minutes to complete this questionnaire.
Comments:________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Please return the questionnaire to the person in charge of the evaluation.
* In French, English or Inuktitut
NABS-SV
9
Section to be completed by the person in charge of the evaluation
Please return the results to:
Last name:
First name:_______________________________
Profession: _________________________________________________________________________
Name of school/school board/institution (of your choice): ____________________________________
Return address:______________________________________________________________________
Phone: (
)_______________________________
Please return the results by: (choose one option)
A.
Regular mail
B.
Fax (48 hours): your fax number (
C.
Email in PDF format (48 hours): your email
)__________________________________________
address_________________________________
Before returning the questionnaires, please ensure the following:
1. The teacher and the parent have responded to all questions, provided the date of birth of the evaluated
child, and adhered to the scoring procedure (poorly scored questionnaires will cause delays).
2. Both questionnaires (parent and teacher) of the evaluated child must be forwarded for correction.
3. If you are sending it by regular mail, please make a copy of them for yourself as they will not be
returned.
Results returned by email or fax must correspond to highest confidentiality standards. By signing below, you are ensuring
to the Laboratoire de mesure du comportement adaptatif that results will be transmitted using secure methods.
_____________________
Signature
___________________
Date
Send the questionnaires by FAX to: (514) 287-0700
or
Send the scanned questionnaires by EMAIL to: [email protected]
or
Send the questionnaires by MAIL to: Laboratoire de mesure du comportement adaptatif
1497, boul. Saint-Joseph Est
Montréal, QC
H2J 1M6
How to reach us:
(514) 287-0700
Email: [email protected]
Fax: (514) 287-0700
Web: www.labadapt.org
10