START Intensive Training
Target Student Baseline Data Form
School Year 2011-2012
Target Student: Click here to enter text.
County & District: Click here to enter text.
Building: Click here to enter text.
Parent Support
1. How frequently are the parents/guardians of the student with ASD consulted regarding issues
related to developing skills, identifying goals, and generalizing skills?
Weekly
1-2 times monthly
Quarterly
Once a year or less
2. How frequently do the student’s parents/guardians participate in team meetings regarding the
student?
Weekly
1-2 times monthly
Quarterly
Once a year or less
3. How frequently do parents/guardians receive communication from special education and/or general
education teachers about student progress and/or behavior?
Daily
Weekly
1-2 times monthly
Quarterly/progress reports
Once a year or less
4. How often are parents invited to attend trainings offered by the school system (e.g., trainings
offered by EPLI trainers, outside speakers, professional development, etc.)
Always
Usually
Seldom
Never
5. What specific supports are offered for the student’s parents/guardian by the school program? (mark
all that apply):
Relevant trainings at the school district/county
Relevant trainings outside the school district/county
Home visit(s)/ In-home consultation
Social work/ Support group services
Parent training
Other Click here to enter text.
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TS Baseline Data Form
Educational Strategies
6. The general education curriculum is a primary focus of instruction for the student with ASD.
Yes
No
7. How often does collaboration occur between regular education teachers and special education
teachers and or related service providers to assure that appropriate accommodations and
modifications are implemented for the student?
Daily
Quarterly
Weekly
Once a year or less
1-2 times monthly
Never
8. Accommodations/modifications are provided in the general education curriculum.
Content Areas/
Classes
Accommodations/
modifications are
necessary during this
class/content area
Language arts
Yes
No
Math
Yes
No
Science
Yes
No
Social Studies
Yes
No
Other content area:
Click here to enter
text.
Yes
No
Other content area:
Click here to enter
text.
Yes
No
Other content area:
Click here to enter
text.
Yes
No
Accommodations/
modifications are wellplanned & implemented
at an appropriate level for
the student
Always
Usually
Sometimes
Never
Always
Usually
Sometimes
Never
Always
Usually
Sometimes
Never
Always
Usually
Sometimes
Never
Always
Usually
Sometimes
Never
Always
Usually
Sometimes
Never
Always
Usually
Sometimes
Never
Person with designated
responsibility for implementing
accommodations/
modifications
Gen. Ed. Teacher
Spec. Ed. Teacher
Paraprofessional
Other: Enter text.
Gen. Ed. Teacher
Spec. Ed. Teacher
Paraprofessional
Other: Enter text.
Gen. Ed. Teacher
Spec. Ed. Teacher
Paraprofessional
Other: Enter text.
Gen. Ed. Teacher
Spec. Ed. Teacher
Paraprofessional
Other: Enter text.
Gen. Ed. Teacher
Spec. Ed. Teacher
Paraprofessional
Other: Enter text.
Gen. Ed. Teacher
Spec. Ed. Teacher
Paraprofessional
Other: Enter text.
Gen. Ed. Teacher
Spec. Ed. Teacher
Paraprofessional
Other: Enter text.
9. A system is used to determine appropriate grading based on the specific accommodations and
modifications to the general education curriculum. Describe.
Click here to enter text.
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TS Baseline Data Form
Paraprofessional Support
10. For what percentage of the school day does the student with ASD receive paraprofessional
support? Click here to enter text.
11. The paraprofessional is:
1:1
Shared with another student or students. Specify how many other students Enter text.
Designated to the classroom
Note: if the student does NOT receive paraprofessional support, the remaining Paraprofessional
Training & Support questions do not need to be completed.
12. In what activities does the student with ASD function independently without receiving direct
paraprofessional support?
Language arts
Lunch
Math
Recess
Science
Hallway transitions
Social studies
Classroom breaks
Music
Other Click here to enter text.
Art
Other Click here to enter text.
Gym
Other Click here to enter text.
Elective Click here to enter text.
Elective Click here to enter text.
13. How frequently does the paraprofessional supporting the student with ASD receive ongoing
mentoring, training and support including direct performance feedback related to interactions with
student?
Daily
Weekly
1-2 times monthly
Quarterly
Annually
Less than annually
14. How does the paraprofessional actively promote student independence? Mark all that apply:
Visual supports
Visual schedules
Organizational systems (e.g. command central, desk or locker system)
Work systems
Self-monitoring systems
Prompt fading
Promote peer interactions (e.g. peer to peer support)
Other Click here to enter text.
Other Click here to enter text.
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TS Baseline Data Form
Functional Communication
15. Does the student have access to and regularly use his/her communication system, and is the student
provided structured communication opportunities?
What system does the
student use for
communication? If the
student does not use a
system listed below,
indicate “none.”
Verbal communication
PECS/picture system
Sign language
Communication device
Gestures
Other: Enter text.
All school
All school
environments
environments,
(lunch, recess,
not at home
hallway, all classes)
and the home
environment
A few school
environments
None or only Student successfully
one school
communicates in all
environment environments
Many structured
opportunities are provided
for the student to initiate
communication.
16. Who does the student with ASD communicate with most during the school day. Rank order.
General ed teacher
Special ed teacher
Paraprofessional/classroom aide
Other students with disabilities
Typical peers
Other: Click here to enter text.
17. Who initiates the most communication with the student with ASD during the school day. Rank
order.
General ed teacher
Special ed teacher
Paraprofessional/classroom aide
Other students with disabilities
Typical peers
Other: Click here to enter text.
18. How is the student with ASD supported to initiate interactions with others? Mark all that apply.
Picture cues or Activity schedules
Verbal prompts
Self-management systems
Structured activities
Environmental structuring
Pairing with peers
Social coaching
Other Click here to enter text.
Student initiates independently at a level similar to peers
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TS Baseline Data Form
Visual Supports
19. Which of the following visual strategies are implemented at an appropriate level for the student
with ASD?
Strategy
Gen Ed
Special Ed
Classroom Classroom
Specials
(art, music,
gym)
Lunch or
snack
Recess,
breaks,
hallways
Is this strategy
used:
Consistently?
Yes
No
Color-coding,
labeling, pictures in
the classroom
Classwide visual
schedule
Independently?
Yes
No
Consistently?
Yes
No
Individual visual
schedule
Independently?
Yes
No
Consistently?
Yes
No
Independently?
Yes
No
Consistently?
Yes
No
Mini schedules for
difficult activities;
visual cues to clarify
expectations
Independently?
Yes
No
Consistently?
Yes
No
Transition
cards/objects
Independently?
Yes
No
Consistently?
Yes
No
Work/routine
procedure checklists
or lists
Social
facts/scripts/stories
Independently?
Yes
No
Consistently?
Yes
No
Other (Please
describe):
Independently?
Yes
No
Consistently?
Yes
No
Enter text.
Independently?
Yes
No
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TS Baseline Data Form
Consistent Behavioral Programming
20. Does the student have a written behavior plan?
Yes
No
21. If yes for #20, was a functional behavior assessment conducted in order to align the intervention
plan with the function of the behavior?
Yes
No
22. If yes for #20, is the behavior plan in place in all school environments?
All school environments (bus, lunch, recess, hallway, all classes) and the home environment
All school environments, not at home
Some school environments
Behavior plan is not regularly used
23. Which of the following behavioral interventions are implemented for the student with ASD?
Strategy
General Special Ed Specials (art, Lunch
Ed
Classroom music, gym)
or
Classroom
snack
Recess,
breaks,
hallways
Is this
strategy used
consistently?
Antecedent or prevention
strategies
Behavioral contracts/selfmonitoring systems
Break cards
Yes
No
Yes
No
Yes
No
Rewards
Yes
No
Time out/removal of
privileges
Yes
No
Other: (Please describe)
Yes
No
Enter text.
Yes
No
Other: (Please describe)
Enter text.
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TS Baseline Data Form
Peer Support
24. Is the student with ASD supported by a peer to peer support program in your school building?
Yes If yes, how many peers support the student with ASD Click here to enter text.
No
25. How many hours a day is the student with ASD in the immediate proximity of typical peers (e.g.,
same classroom, same playground area, same table in the cafeteria)?
all day
4 hours or less
none of the day
5 hours or less
1 hour or less
6 hours or less
2 hours or less
3 hours or less
26. Where does the student with ASD eat lunch?
Separate classroom/lunchroom
School cafeteria at a different time from typical peers
School cafeteria at a separate table from typical peers
School cafeteria integrated with typical peers
27. In which of the following school environments is there at least one peer who has received
information, training and support related to the individual skills and needs of the student with
ASD? (mark all that apply)
There are no trained, typical peers in the school environment with the student with ASD
There is at least one trained peer in all of the student’s academic school environments (general
academic courses or content areas)
There is at least one trained peer in all of the student’s non-academic specials (physical
education, music, art, etc.)
There is at least one trained peer in all of the lunch/ recess activities
There is at least one trained peer during all of the transition activities (transitions in the hallway,
classroom transitions, etc.)
28. What extracurricular activities/clubs does the student with ASD participate in? (List all)
Click here to enter text.
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TS Baseline Data Form
Team Process
29. How often do team meetings occur related to this student’s progress?
Weekly
Twice a month
Once a month
Quarterly
Annually
30. How often do team meetings result in a written action plan with appropriate completion of action
plan items?
Always
Usually
Seldom
Never
31. During team meetings for this student, do all members, including parents, teachers, administrators
and paraprofessionals, work together and function as a successful team to effectively support the
student with ASD?
Always
Usually
Seldom
Never
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TS Baseline Data Form
Data Collection
32. Adequate data is collected in the following areas:
Content Area
Curriculum
based
assessments
Specific skill
development
Language arts
Behavior
observation
Social or
communication
progress
Data is
summarized and
used for decision
making and
program
improvement
Yes
No
Math
Yes
No
Science
Yes
No
Social studies
Yes
No
Other content area:
Yes
No
Click here to enter
text.
Other content area:
Yes
No
Click here to enter
text.
Other content area:
Yes
No
Click here to enter
text.
START Materials ’11-12
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TS Baseline Data Form