START K-12 Intensive Training
Target Student Baseline Data Form
School Year 2014-2015
Target Student: ____________________________
County & District: __________________________
Building: __________________________________
Family Support and Involvement
1. How frequently are the parents/guardians of the target student with ASD consulted regarding issues
related to identifying goals, developing skills, and generalizing skills?
Weekly
1-2 times monthly
Quarterly
Once a year or less
2. How frequently do parents/guardians receive communication from special education and/or general
education teachers about target student progress and/or behavior?
Daily
Weekly
1-2 times monthly
Quarterly/progress reports
Once a year or less
3. What specific supports are offered for the target student’s parents/guardian by the school program?
(Check 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
Relevant resource materials
Other Click here to enter text.
START Materials ’14-15
2
TS Baseline Data Form
Educational Strategies and Supports
4. On average, how much time does the target student spend in general education each day?
all day
3 – 4 hours
none of the day
4 – 5 hours
1 hour or less
5 – 6 hours
1 – 2 hours
2 – 3 hours
5. Is the general education curriculum the primary focus of instruction for the target student with
ASD?
Yes
No
6. How often does collaboration occur between regular education teachers and special education
teachers and or related service providers for the target student with ASD?
Daily
Monthly
Never
Weekly
Quarterly
1-2 times monthly
Annually
7. Is differentiation provided in the general education curriculum at the target student’s output level in
order to increase active engagement in the curriculum?
Yes
No
Content Areas/
Classes
Language arts
Math
Science
Social Studies
Other content area:
Click here to enter text.
Other content area:
Click here to enter text.
START Materials ’14-15
The curriculum is differentiated at
the target student’s output level for
this content area
Always
Usually
Sometimes
Never
Always
Usually
Sometimes
Never
Always
Usually
Sometimes
Never
Always
Usually
Sometimes
Never
Always
Usually
Sometimes
Never
Always
Usually
Sometimes
Never
3
TS Baseline Data Form
8. How is progress on academic goals/objectives measured? (Check all that apply)
Curriculum-based measures
Traditional tests and quizzes
Assignments
Individualized/alternative assessments
No academic goals identified for target student
Other Click here to enter text.
Other Click here to enter text.
9. A system is used to determine appropriate grading based on the general education curriculum.
Yes
No
Not using general education curriculum
Describe:
10. What state test does the target student take?
Standard state assessment (e.g. MEAP)
Alternative assessment
11. Does the target student participate in his/her own IEP meetings?
Yes
No
12. If the student is 14 or older, have they participated in any of the following? Check all that apply.
Paid employment
Internship/apprenticeship
Volunteer experiences (on a regular basis)
Technical training (e.g. tech program)
Other Click here to enter text.
START Materials ’14-15
4
TS Baseline Data Form
Adult Support
Note: If the target student does NOT receive paraprofessional support, answer #13 only.
13. For what percentage of the school day does the target student with ASD receive paraprofessional
support?
None of the school day
0-25% of the school day
26-50% of the school day
51-75% of the school day
76-100% of the school day
14. The paraprofessional is:
1:1
Shared with other students (How many other students Click here to enter text. )
Assigned to the classroom
15. In what activities does the target student with ASD function independently without receiving direct
paraprofessional support?
Language arts
Lunch
Math
Recess
Science
Hallway transitions
Social studies
Classroom breaks
Music
Personal care routines
Art
Other Click here to enter text.
Gym
Other Click here to enter text.
Elective Click here to enter text.
16. How frequently does the paraprofessional supporting the target student with ASD receive ongoing
mentoring, training and support including direct performance feedback related to interactions with
the target student?
Daily
Weekly
1-2 times monthly
Quarterly
Annually
Less than annually
START Materials ’14-15
5
TS Baseline Data Form
Functional Communication Systems
17. Does the target student have access to a functional communication system that is used across
settings?
Yes
No
18. What system does the target student use for communication? Check all that apply.
Full verbal communication
Emerging or limited verbal communication
PECS/picture system
Sign language
Communication device (e.g. iPad)
Gestures
Other
19. Does the target student have access to a functional communication system at home?
Yes
No
20. Who initiates the most communication toward the target student with ASD during the school day
(Rank order).
General education teacher
Special education teacher
Paraprofessional/classroom aide
Other students with disabilities
Non-disabled peers
Other: Click here to enter text.
21. Who does the target student initiate communication to most of the time during the school day
(Rank order).
General education teacher
Special education teacher
Paraprofessional/classroom aide
Other students with disabilities
Non-disabled peers
Other: Click here to enter text.
22. How is the target student with ASD supported to initiate interactions with others? (Check 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.
Initiates independently at a level similar to peers
START Materials ’14-15
6
TS Baseline Data Form
Visual and Organizational Supports
23. What visual and organizational systems are actively used to promote target student independence?
(Check all that apply)
Visual supports
Visual schedules
Organizational systems (e.g. command central, desk or locker system)
Work systems
Self-management systems
Prompt fading
Promote peer support
Other Click here to enter text.
Other Click here to enter text.
24. Which of the following visual strategies are taught and implemented at an appropriate level for the
target student with ASD? (Mark an X for all that apply; Mark NA if student is not in one of the
settings)
Strategy
General
Education
Classroom
Special Education
Classroom
Color-coding, labeling,
pictures
Class-wide visual schedule
Non-classroom
settings
NA
Individual visual schedule
Mini schedules for
activities; visual cues to
clarify expectations
Transition cards/objects
Work/routine procedure
checklists or lists
Social facts/scripts/stories
Other (Specify):
Other (Specify):
START Materials ’14-15
7
TS Baseline Data Form
Positive Behavioral Interventions and Supports
25. Does the target student have a written behavior plan?
Yes
No
26. If yes for #24, was a functional behavior assessment conducted in order to align the intervention
plan with the function of the behavior?
Yes
No
27. If yes for #24, in what environments is the behavior plan used?
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 used consistently
Behavior plan is applicable to specific environments only. Specify:
28. Which of the following behavioral interventions are implemented for the target student with ASD?
Antecedent or prevention strategies
Behavioral contracts/self-management systems
Break cards
Reinforcers / Rewards
Time out/removal of privileges
Teaching replacement skills
Other: (Please describe)
Other: (Please describe)
29. Does the target student have a crisis plan in place for the emergency use of seclusion or restraint?
Yes
No, but is needed
No history of crisis in the past 2 years
START Materials ’14-15
8
TS Baseline Data Form
Peer to Peer Support
30. Is the target student with ASD supported by a peer to peer support program in your school
building?
Yes If yes, how many peers support the target student with ASD ______
No
31. How many hours a day is the target student with ASD in the immediate proximity of typical peers
(e.g., same classroom, same playground area, same table in the cafeteria)?
all day
3 – 4 hours
none of the day
4 – 5 hours
1 hour or less
5 – 6 hours
1 – 2 hours
2 – 3 hours
32. Where does the target student with ASD eat lunch?
Separate classroom/lunchroom
School cafeteria at a different time from non-disabled peers
School cafeteria at a separate table from non-disabled peers
School cafeteria integrated with non-disabled peers
33. 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 target student with
ASD? (Check all that apply)
There are no trained peers in the school environment with the target student with ASD
There is at least one trained peer in all of the target student’s academic school environments
(general academic courses or content areas)
There is at least one trained peer in all of the target student’s specials/electives (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,
bus, etc.)
34. What extracurricular school activities does the target student with ASD participate in? (Check all
that apply)
Sports
Clubs
Music/theatre
School events (e.g. family fun night, dances, movie night)
Other Click here to enter text.
Other Click here to enter text.
START Materials ’14-15
9
TS Baseline Data Form
Team Process
35. How often do team meetings occur related to this target student’s progress?
Weekly
Twice a month
Once a month
Quarterly
Annually/IEP only
36. How often do team meetings related to this target student result in a written action plan with
appropriate completion of action plan items?
Always
Usually
Seldom
Never
No regular team meetings
37. During team meetings for this target student, do all members, including parents, teachers,
administrators and paraprofessionals, work together and function as a successful team to
effectively support the target student with ASD?
Always
Usually
Seldom
Never
No regular team meetings
START Materials ’14-15
10
TS Baseline Data Form
Data Collection
38. How often is data collected in the following areas for this target student with ASD?
Curriculum based
assessments
Daily
Weekly
Monthly
Quarterly
Annually
Never
How often is data
summarized and used
for decision making?
Daily
Weekly
Monthly
Quarterly
Annually
Never
Specific skill
development
Daily
Weekly
Monthly
Quarterly
Annually
Never
How often is data
summarized and used
for decision making?
Daily
Weekly
Monthly
Quarterly
Annually
Never
Behavior plan
Daily
Weekly
Monthly
Quarterly
Annually
Never
How often is data
summarized and used
for decision making?
Daily
Weekly
Monthly
Quarterly
Annually
Never
Social-communication
skills
Daily
Weekly
Monthly
Quarterly
Annually
Never
Daily
Weekly
Monthly
Quarterly
Annually
Never
How often is data
summarized and used
for decision making?
Daily
Weekly
Monthly
Quarterly
Annually
Never
Independence
How often is data
summarized and used
for decision making?
Daily
Weekly
Monthly
Quarterly
Annually
Never
Other:
START Materials ’14-15
11
TS Baseline Data Form
Additional Information
Please provide any educationally relevant, additional information about the target student that was not
captured by the questions above:
If you have any comments about the form and how it could be improved, please provide feedback here.
START Materials ’14-15
12
TS Baseline Data Form