Reinforcer Survey

Reinforcer Survey

Secondary Level

Name 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

_____ice cream _____candy _____potato chips_____cookies _____other

_____fruits_____cold cereal_____hot cereals_____cheese (please list):
_____sugar _____pretzels _____sandwiches _____milk
_____soda _____pastry_____water _____pudding
_____salads _____pasta_____hamburgers_____fries
_____nuts _____vegetables_____steak _____eggs
_____rice _____hot dogs_____fruit juice _____popcorn

What are the student’s three favorite foods? 1.______

2. ______3.______

How much does the student like: Loves it Likes it Doesn’t Noopportunity/

like it unable to do

Playing Games...... ______

Looking at magazines (kind?)....______

Drawing pictures/painting...... ______

Building Models...... ______

Listening to music ...... ______

Watching movies ...... ______

Special Interests (name it)...... ______

Historical facts...... ______

Sport activities...... ______

Tracing designs ...... ______

Their pet(s)...... ______

Describe:______

Imitating the
physical actions of others....______

How much does the student like: Loves it Likes it Doesn’t No opportunity/

like it unable to do

Walking the halls______

Looking up facts...... ______

...... ______

Learn a foreign language...... ______

Do Math problems...... ______

Puzzles...... ______

Hides...... ______

Water play/swimming...... ______

Good Hygiene...... ______

Interacting other peers...... ______

Activities with the family...... ______

A trip to the zoo...... ______

A trip to the library...... ______

Visiting a park...... ______

Visiting the dentist...... ______

Visiting the doctor...... ______

Camping...... ______

Playing outside...... ______

Watching television...... ______

Snacking on foods...... ______

Going shopping...... ______

Going to movies...... ______

Being read or told stories...... ______

Reading to others...... ______

Dance...... ______

High Fives...... ______

Clubs/Organizations...... ______

Being praised...... ______

How much does the student like: Loves it Likes it Doesn’t No opportunity/
like it unable to do

Being around the family...... ______

Being around other peers...... ______

Being alone...... ______

Receiving gold stars, points,

or stickers...... ______

Getting letters/notes/cards...... ______

Reading books...... ______

Listening to the radio...... ______

Riding a bicycle...... ______

Swinging...... ______

Playing on a computer...... ______

Other Technology...... ______

Listening to music...... ______

Playing an instrument...... ______

Being with parents...... ______

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: ______

______

Developed by Chris Bohn