Vineland-3 Vineland Adaptive Behavior Scales"—Third Edition Domain-Level anes Name Todays Dat famines’ Date amines ge txaminee’sSex:] Female CI ale Respondents Name spondent’Reaonsiptothefaninee: Cotter Cl tier InerviewersName ‘IRECTIONS ‘omplete instructions for administering this form are provided in hhapter 2 of the Vineland-3 Manual. The Manual also includes coring criteria for the items in Appendix H, which you may wish » have available when conducting the interview. core each item 2, 1, or 0 as follows: fircle 2 if, when the behavior is needed or appropriate, the dividual usually performs it without help or prompting (or if c/she performed the behavior when younger, but has now urgrown it. ircle1 if, when the behavior is needed or appropriate, the dividual sometimes performs it without help or prompting, PEARSON Copyright © 2026 NCS Pearson, Inc. Al rights reserved For inquiries and reordering: 800.627.7271 www. PearsonCinica.com Circle 0 ifthe individual never performs the behavior, or never performs it without help or prompting. Whether he/she hasn't learned the behavior, is not physically able to perform it, is not expected oF allowed to perform it, o chooses not to perform it, circle 0. Some items use a different scoring system: 2» Yes, 0 = No. This is indicated in the booklet. Tf the respondent has not had the opportunity to observe a ‘behavior, ask him/her to estimate a score for that item. In addition to-marking the icem score, also check the box to the right of the item score, in the column labeled Check if Est. IF the individual performed a behavior when he/she was younger, but has now outgrown it, cicle 2. Do not check the Estimated box. Some items include a Scoring Tip, indicated with the symbol Use the tips to help you score those items. @PsychCorp Procict Number 31323SENET a Sometimes, 0= Never ITERVIEW TOPIC A: VOCABULARY cas geste interven estan: What objects and actions does Inamel say the words fr, like “dog” or “eat”? co ames teat three tions (or example, drink/ drinking, eaeating, play/playing)- Ni east thr (kc ple, drink/drinking, 1 play/playing). eno D_whatsboutisblingactions. ke crinking ating orpaying? 2. Says atleast 50 words, Score2for Yes or forNo. 200 D_Avouthow many total words doeshelshe say? ITERVIEW TOPIC B: UNDERSTANDING QUESTIONS gested interview Question: Tell me how (namel responds to “wh” questions, like “what, where, and who?” 3. Respond wuss hate wr Foreampl when ner heal 0 | | Era teng eta ha? 3 [ “4. Responds to questions that use where (for example, when asked “Where did Felipe go?” points where Felipe went). ue oo coesionigeasearatunvner 5. Responds 10 questions that use who (for example, when asked “Who is thar?” replies “Auntie Kesha"), ‘D How about questions that use who? roo gested Interview Question: What are some examples of the sentences that [name] says? (6. Uses phrases with a noun and a verb (for example, “Mommy stay” “Give ball”). @_ what about using both anoun and a verb, such as “Mommy stay” or “Give ball"? 7. Uses simple adjectives to describe’ D_ what about using adjectives 5 (fr example, dirty, pretty, big, loud). lescrbe things suchas “Pretty ture” or "Big doggie"? '8. Uses possessives in phrases or sentences; grammar need not be correct (for example, “Thisis mine,” "Your book,” “This is Carol's desk”). 2100 Mommy's" or "your" and grammar mast be correct (for example, “T want,” “Theie ball," “Call her Br r ple, ? oO ITERVIEW TOPIC C: USE OF GRAMMAR = 4 9, Uses pronouns correctly; pronoun ge D wnaowvingponinonety from othe" bal went berweon tec") 2100 D Howabourusing the words behind, In frontof and between? ITERVIEW TOPIC D: FOLLOWING INSTRUCTIONS gested Interven Question: What are the most complicated kinds of instructions that inamel follows? 11, Followsinstructions with two related zetions (for example, “Pick up those toys and put them away"; “Get your coat and patiton"), zaeo) OO 13, Follows instructions requiting three actions (for example, “Get dressed at breakfast and brush your teth"). D. what about three-step instruct your teeth”? i 14, Follows instructions in “if-then" ike "Get dressed, eat breakfast, ane sm (for example, “IFyoutre thirsty, then get a drink’; “Ifyou are cold, then get asweatshitt”). D what about if-then instructions like “ifyou're thirsty, then get a drink” or "if you cold, then geta sweatshitt”? 15. When instructed to do something several hours later, remembers to do it (or example, “When you get home from | school, let the dog out”). Ae D tow often does he/she remember to do something that you ask to be done much later that day, for example, etting the dog out afterschool? | Vinelnd-3 Dorin Lvl en formSOMMUNICATION Response Options: 2 Usually, 1=Sometimes, 0 = Never NTERVIEW TOPIC E: STATING PERSONAL INFORMATION gested interview Question: What Information does {name} state about himself/herself, ike his/her name, address, et and birthday? th 16. Saysown firstname or nickname. Ei natentcnremam al 17, Says firstand last name when asked; saying first name only doesn’t count aes D what about when you ask for his/her full name? Gps cups ies ry le ri oT pea Ps Sioreksone ada eer o D wnat about his/her complete home address? SO ap eh nnd Sey rapa @_ How about the month and day of his/her birthday? 2100 NTERVIEW TOPIC F: ATTENDING TO ENTERTAINING MATERIAL aggested nerven Questor: For how long does [name] pay attention to something he/she likes, such asa story, TV show, movie, or live performance? 20. Pays attention toa story for atleast 15 minutes. Score 2if the individual dié this when younger, but has now outgrown listening to stories. 2100 D Forhow long does he/she listen toa story? 21. Pays attention toa show for atleast 30 minutes and understands whatis happening. @ Forhow long does he/she pay attention toa TV show, movie, orlive performance, and how can you understands what is happening? Wifhershe 2100 22. Paysattention to show fora least 60 minutes and understands whatis happening. ‘D Forhow long does he/she pay attention to.a TV show, movie, or live understands whatis happening? NTERVIEW TOPIC G: ATTENDING TO INFORMATIONAL MATERIAL _ggested interview Question: For how long does [name] pay attention in settings such as school, church, or a meeting? ‘ays attention toa 15-minute informational presentation and understands what is being sad D Forhow long does he/she pay attention to information being presented that's serious or educational, andhoweanyou 2 1 0 CJ tellif he/she understands wha 2A Faxes 30 ons inorstienl pian ed tanic ats og wi, @ Forhow long does he/she pay attention to information being presented that's serious or educational, andhowcan you 2 1 0 O] tellithelshe understands whats being sald? NTERVIEW TOPIC H: EXPRESSING IDEAS AND EXPERIENCES Aggested Interview Question: How does [name] talk about his/her own ideas and experiences? 25, ‘Tells the basic part of familia story orbook or move plot (the characters, what happens, how it nds, et) - @ How much detail doeshe/she elabout. = 26, Uses own knowledge or opinions to comment on things, situation, and emotions (or example, I chnk be’ mad ater brecttte she aid mean things about him"). ao @. whatahout using his her own knowledge or opinionsto comment on things, for example, why friends mad atsomeona? 27. Tellsabour everyay (i.e, routine experiences in detail for example, when asked what e/the did witha frend voday, tells who was involved, where the atvty took place et). baaio D_ How much detail does he/she give when he/she talks: friend'shouse? 28, Clasfies by restating with different words when he/she s not fully understood at fet. lowing, what does he/she do tohelp youunderstandwhat =2 1:0 O] out everyday experiences, like what happened ata D tthaisnets tating you something, and you men’ quite heshe trying tosay? Vinelané-3 OomaiLerelinewiew fom 3Response Options: 2 Usually, 1=Sometimes, 0= Hever NTT ERVIEW TOPIC I: LEFT AND RIGHT a ested here Question: What kind of instructions involving teft and right does name] follow? Ls 29. Identifies eft and right on own body (for example, hands, feet, arms). eo D What about identifying left and right on his/her own body? 30. Follows instructions involving left and right (for example, “Go to the left" D How does he/sherespond to directions that involve left and right? 2100 TERVIEW TOPIC J: BEGINNING WRITING ested incerview Question: What kinds of things does [name] write on his/her own, without help? “SH. Copies own first name without mistakes. i Score 2if the individual did this when younger, but has now outgrown it z10O ¥ D How weltdoes hershe copy hisiher first name? 32. Writes at east 10 simple words from memory (for example, bat, bal, the); may make small spelling errors. © Score 2 for Yes or 0 for No. oC) cerrorsin spelling or grammar. B Score 2for Yes or for No D Howtong are the emails, stories, letters, or other longer things that he/she writes? 4ested interview Question: What does [name] do to find information, like using a dictionary or other sources in a library oronthe Internet? 35. Finds or sorts things in alphabetical order (or example, finds a name in an alphabetized address book or list of phone ‘numbers, finds a word ina dictionary, alphabetizes alist of words or movie titles) 2100 TD Howoften is heishe able to find things that are in alphabetical order—for example, words ina dictionary—or put words or actual things 36. Accurately interprets visual instructions (or example, asrembly instructions, directions shown on a map). H 3 TERVIEW TOPIC K: WORKING WITH WRITTEN INFORMATION | ‘books ar musicinalphabe | @ tow welt doesnelsheunderstnd and follow visual instuctons,suchasassemblynstuctins, grams 2100 | | oraectontonamapr fee s 57. User atable of ontnts orindss ond information within a book lectone ours Rail D whataboutsing atabieof contents oindesto nd informaton within booker electron ie? 38, Useehe Interne or ibrery find information for wrtinga pape orcompletinga job signmen ny ing pape or completinga job angen alo D to 2+ he/she go about finding information that helshe needs to write a paper or complete ajob a TERVIEW TOPIC L: READING LEVEL gested interview Question: At about what grade level is [name] reading and comprehending? 39, Reads and understands material ofa second-grade level or higher i | 51 Score 2for Yes or for No, a ote 5 D_ Arabour what grade level is he/she reading and comprehending? ‘ ). Reads and understands material ofa fourth-grade level or higher. Score 2for es or for No paeeo) C D Arabout what grade level is he/she reading and comprehending? |. Reads and understands material of «sixth-grade level o higher. Score 2for Yes or for No, aoe OC @_ Atabout what grade tevelishelshe reading and comprehending? Reads and understands material ofa ninth-geade level or higher. 1 Score 2 for Yes or 0 for No. oo 0 TD Atabout what grade level is he/she reading and comprehending? Vineland-3 Oomai-ee deve FamRUN Response Options: 2 Usually, 1=Sometimes, 0= Hever NTERVIEW TOPIC M: ADVANCED WRITING uggested interview Question: What kinds of papers does [name] write for school, and what is the process that he/she uses ona towrite them? mi 43. Writes short reports or summaries (for example, a summary of something read) a least three sentences long; must use ‘own words rather than simply borrowing or copying from other sources. 1 Score 2ifthe individual did this when younger, but now no longer needs to write reports or summaries, D_ what about writinga short report or summary of three sentences or more? 44, Writes reports, papers, or essays atleast one page long; must use own words rather than simply borrowing or copying. from other sources. W 1 Score 2if the individual di this when younger, but now no longer needs to wile reports, papers, OF essay. D_ tow tong are the reports, papers, or essays that he/she writes using hsiher own words, not ust copying something? 45. Edits or correets own written work before handing in (for example, checks punctuation, spelling, grammar, ete); use of computer spell-checkeris okay. 2100 @) Whatsdoes heise doto checkand correct hisyher written work efore handing ItIn? Tao E : 2= Usually, = Sometimes, 0 = Never NTERVIEW TOPIC A: EATING AND DRINKING oot ‘uggested Interview Question: Tell me how (name) feeds himself/herself at the table, and how he/she drinks liquids. ee 1. Drinks from a regular eup oF glass (sippy cups don't count), eo 2, Feed self with spoon without pling. D wow seocusiapaspoont il 3. Cuts casy-to-cut food witha table knife (or example, fish, pancakes, butter). D How doeshe/she usea table knife? 2100 NTERVIEW TOPIC 8: TOILET TRAINING sggested Interview Question: Tell me how [name] uses the toilet. 4. Usinwes in wet or poty ha parent or eegvermay ae 210 D eienuaaa oa ciara _ ego 7 Deter tet o pry chy pret orcregie myn oe an : 46, Uses the oiler during the day and at cristina Th advancing D How much help does he/she need? NTERVIEW TOPIC C: WASHING AND BATHING -ggested Interview Question: What is [name] doing in terms of washing and bathing? 7 Washes hands using soap and water and: D_ what about washing hisiher hands? hems doesnot needa turn thewateronand offoradjustthe temperature.) yy P 2100 D. whatabout takinga bath ora shower? Vineland-3 Damir! ieiew fra 5DEE TERVIEW TOPIC D: PUTTING ON CLOTHES AND SHOES apsted neve Question: What kinds of clothing does fnamel put on by himself/herself, and how often does he/she et do it correctly? “ 9, Pats clothing on with the right side forward and corect side owt. @D_wnatabout putting histor loth le forward andthe correctside out? caag O 10, Puts shoes on the correct feet and secutely tes or fastens them. D whatabout tying or fastening histhershoes? 2100 TERVIEW TOPIC E: HOME SAFETY gested interview Question: What safety precautions wi in the home environment does [name] follow? TH, Tsewefl around ot objet (or example, te stove or ven, an open ir) Q enantio . 2100 [12 Tecarefatwhen using sharp objects or example sor kniven GD -whatabeatsharpthngstabatvesoe scan? ee iB. Understands wha odoin dangerous station or example, when o getielp, when eal 11, how distance self from danger). ae OC) D_what does helshe understand about what todo in dangerous situations for example, when to get help or call? | 14, Is careful when operating household appliances or equipment (for example, vacuum cleaner, lawnmower, iron, Bf pomactocl). 21 eee one eee oo er power ols? 15, Secures home agsinst intruders when leaving home (locks door, closes windows, turns on alarm, ee). D_whatdoeshelshedotokeep intruders ot when helshe leaves home? TERVIEW TOPIC F: CLEANING UP AFTER SELF gested Interview Question: What does name] do to clean up after himself/herself, like with spills and dirty clothes? 16. Wipes up own spills; must get wiping material and clean the spill adequately. | What does helshe doit he/she spills something? [G7 Removes diy shoes or wipes them on a doormat before entering residence. mo f © Whatdoeshelsnado thither shoes aecirty when bafets ging int someone house? 1. Puts dirty thes inthe proper place to be washed (for example, alnundry Basket or chute). ato FED weatabouthisnerdiey clothes? Hee as clean elothes away wire ‘example n drawers or closet, on books 19, Puts clean clothe ay where they belong (for: ipl, in dr 2100 D. whacavout hier cleanclotes TERVIEW TOPIC G: SAFETY OUTSIDE THE HOME ested ntenvew Question Tell me what [name] does to stay safe outside the home. 21. Remains within sale distance of caregiver when in public places being carried, pushed ina stroller, ete. doesn't count. 1 Score 2ifthe individual did this when younger, but has now outgrown it. @. what about staying within sate distance from you when you are out in publet 22. Understands signs or symbols used to indicate danger for example, skull and crossbones for poison, crcl with slash for “don't do”). 2100 D what does hejshe know about signs or symbols that are used to indicate danger, ike the warning sign that's acircle with a slash through et 23. Follows fey precautions in workandforkisure actives Gor example wears lis equipment, wes ouion when operingtole and machine) 2100 sion ia basset Vineland-3 Boman Lee inteiew FrmNTERVIEW TOPIC H: PHONE AND TECHNOLOGY USE a uggested interview Question: How does [name] use a phone and other technology like a computer to communicate with people? _¢h 24. Talks to familiar person usinga phone, computer, or other electronic device; docs not need to place the cal. | ay Reanim _ ago 25. Knows what phone umber to callnan emergency and how o make the call or ramp nows how eal Horan energeny con). 2100 D_ Whar does heshe know about makin roeney? = 26. Usesattest evo soca interaction technolgies (Or example, personal mal texting, ail medi, Skype tlephone calle don tconn) 2100 purposes STERVIEW TOPIC I: HEALTH AND HYGIENE ggested Interview Question: Tell me what [name] does to stay healthy, including caring for his/her teeth. 2 Reetherestcnaar ous oncpannen tate bhabageedabs Rae, eta ur ncaa ete hic ao D_ what about brushing hisiher teeth? 28, Makes healthy eating choices (eats a balanced diet, eats unhealthy foods in moderation, ete D_ How often does he/she choose to eat healthy foods? 29, Shows awareness that physical exercise is good for people for example, states that exercises health, that people should exercise, ete). D_ what does helshe know about the health benefits of exercse? 30, Covers mouth and nose when coughing or snezing. at D. wnatdoestelsnedowhenhelte coughs orsneres? 31, Takes own temperature when needed. @D_ what about taking hisihe ntemperature? NTERVIEW TOPIC J: USING MONEY sggested Interview Question: Tell me what [name] knows about money, and how he/she uses money. 32. Understands that money is used to buy things. ‘ombines coins to equal a specific amount (for D what ifhe/she needs to combine coins kes small purchases at a store (for example, candy, stickers). D How often does he/she make purchases by himselt/herself? 35. Checks change to make sre its correct afer buying something D howofendoeshelse check his/her change ter buying something tomate seis comect? 36, Cartes orstoresmoneydebit carded cards safely, without losing or example,inaallet purse ormoney el). yg Oy D_ what does he/she do to keep his/her money, debit card, and credit cards safe when out in public? NTERVIEW TOPIC K: RIGHTS AND RESPONSIBILITIES aggested Interview Question: What does [name] understand about people's rights and responsibilities, like the right to vote or the need tofollow rules and laws? 37, Underatands and follows community ulesand laws for example, ules and laws regarding tering, pet conl, respecting others property ct). 2100 D_what about community rules and lan ke those regarding tering, et control and respecting others pro [38 Undermandstherighttovor. D_ what about the right to vote? 2100 Vineland-3 Danneel ie form 7PAILY LIVING SKI NTERVIEW TOPIC L: FOOD PREPARATION gested interview Question Tell me what things inamel does to prepare food. f 39, reparcr simple snack or meal forexample, a sandwich, cheese and crackers, microwave foods) und crackers, or microwave food? 2100 7a Wii liad epee ning or coking om. D_ what about washing fruits and vegetables before eating or cooking them? 41. Putsleftover food away (for example, in plastic bags or wrap, in containers) D_ what about putting away leftover food when he/sheis supposed to? 42, Uses atleast to simple kitchen appliances (for example, toaster, microwave, electri ean openes). o ‘DL What kitchen appliances does he/she use, things like a toast tric can opener? ae 48._ Uses the stove or oven for cooking or baking (eurns burners on and off, sets oven temperature, et) D what abourusing the stove or oven? 2100 NTERVIEW TOPIC M: ACHIEVING GOALS sggested Interview Question: Tell me about some goals that [name] has set for himself/herself and actually achieved. “44, Setsa short-term goal and achieves it (for example, completes all homework by Thursday nightin order to have the ‘weekend free) 2100 ‘D_ What are some short-term goals that he/she has achieved recently? 445. Sets agoal that can be done in six months or more and achieves it for example, works and saves money to buy ‘something expensive, gets in better physical shape). 2100 HE —_& teow about any gots that needsx monthsor morete achieve? OTN a Usuc tesponse Options: NTERVIEW TOPIC A: PLAYING WITH OTHERS te sages Interview ueston: How does name] play or socialize with others? f 1L. Plays interactively with one or more children for at Teast 5 minutes with someone older supervising. 1 Score 2ifthe individual did this when younger, but has now outgrown it. a 19 de interactively with one children when someone 2, Plays interactively with one or more children for atleast 30 minutes with someone older supervising. 1 Score 2ifthe individual aid this when younger, but has now outgrown It D How tong does he/she play interactively with one or more other children when someone olderis supervising? D what does he/she do when achild nearby is acting aggressive by trying to hurt other children or destroy things? 4. Seeks out others for play or companionship (for example, asks others to play or spend time together). D How often does helsh "3._ Protects selfby moving away from those who ty to hurt others or destroy things (those who bite, hit, throw things, smash things, et). 5. Joins in witha group when nonverbal cues indicate that he/she is welcome. @ what does he/she do when a group lets hinvher know without words that they want him/herto oinin,tikemotioning 21 0 come join us" or pointing toan empty chair? 6. Refrains from entering a group when verbal cues indicate that he/she is aot welcome. Pao D_ What does heishe do when told that he/she is not welcome tojoina group activity? Vineland panier Iwi FamResponse Options: Sometimes, 0 = Never SeLaN Zire INTERVIEW TOPIC B: EXPRESSING AND RECOGNIZING EMOTIONS Suggested ntersew ueston: How do you know what feelings or emotions name] is having, and whether he/she knows re what emotions others are having? i 7. Uses words to express own emotions (for example, “I'm happy,” “I'm seared,” “I don't like him”) =p (for example, Pm happy » ao D_ what words does he/she useto show his/her emotions? 8, Recognizes emotions in others for example, might say “You lok sad” or "Rachel is happy” D How canyoutell that he/she knowe what oth ecling? 2100 NTERVIEW TOPIC C: FRIENDSHIPS Suggested Interview Question: Tell me about name|'s friendships. 9. ‘Tries to make friends with others his/her age (Cha is, shows particular interest in interacting with certain other children). o D How does heishe try to make isther age? aa 10, Maintains friendships over time (fr example, has had the same good frend for overa yea). o @ How tong have his/her best friendships lasted? GO NTERVIEW TOPIC D: FOLLOWING SOCIAL RULES Suggested Interview Question: When playing with others, what does [name] do in terms of sharing things, taking turns, and following rules? 1. Shares toys or possessions when told todo so. D How often doerhe/shesharewhen hesheistoldto? a100 12, Asks permission before using things that belong to or are being used by another. GD, How often does helshe ask permission before using something that belongs to someone elseorthatsomeoneelse = 2:10 C7 Isusing? 13. ‘Takes turns when asked while playing games or sports. Ajolal GD How often does heishe take turns when heishe is asked to? 14, Follows rulesin games or sports without being tld todo so. D_ How oftendoesheishe follow r 2100 in games or sports without baing told to? NTERVIEW TOPIC E: ASKING FOR AND ACCEPTING HELP Suggested Interview Question: What does [name] usually do in terms of asking for help when he/she needs it to figure out how to do something and accepting helpful ideas from others? 15. Requests help when encountering a problem beyond own capability to rolve (for example, a computer problem, fixing something). 2100 D, How often does helshe ask for help when helshe can't figure out how to de something? 16, Accepshepfil suggestions or solutions fom others D Howisheishe about accepting helpful suggestions rom others? 219 fa) NTERVIEW TOPIC F: EMOTIONAL CONTROL Suggested Interview Question: What kinds of things cause [name] to get upset, and how does he/she usually respond? 17, ‘Transitions exily from one activity to another @ How oftenishesheable to change rom one activity to anather ike playtinetobath tine without gettingupser? 2 1 0 CT 18. Uses words or gestures to express distress rather than sereaming, hitting, throwing something, et. D_ what about using words or gestures when helsheisupset rather than screaming iting throwing something, 2100 andzoon? 19. Controls anger or hurt feelings when he/she does not get his/her way (for example, when not allowed to wate television ‘orattend.a party, when a suggestion i ejected by a friend or supervisor). GD How does he/she usualy respond when heishe doesn’t get his/her way, ike not being allowed to do something that he! he wantsto? 2100 Vineland-3 Dema-eeInenew fom 9OCIALIZATION an Response Options: NTERVIEW TOPIC G: INTERPERSONAL APPROPRIATENESS \ggested interview Question: What does {name} do that shows that he/she understands what people consider proper, like i how close to stand to other people, how to adjust his/her voice for the situation, and so on? 20, Maintainsan acceptable distance between self and others in social situations (fr example, docs not get too close vo ‘another person when talking). 28 C1 D_ wat about not standing too away trom other peoplein social situations? f 21, Maintains cultural rate eye contact during social interactions. ly appropriate eye contact during ract 2100 ©. what about making proper eye contact when he/she interacts with people? 22, Speaks using aloudness, speed, and level of excitement thats appropriate for the conversation, eo D_ what about adjusting his/her voice to the proper loudness, talking speed, and level of excitement for the conversation? 23, Talks wich others without interrupting or being rude. D_ wharabouttatking with others without interrupting ATERVIEW TOPIC H: ADAPTING BEHAVIOR TO THE SITUATION lggsted Interview Question: As we get older, we learn to change our behavior to fit the situation, like lowering our voice when others nearby are concentrating. In what ways does [name] adjust his/her behavior to fit the situation? 2a,_ Changes behavior intentionally depending on how well he/she Knows another person (for example, acts more formally ily member). nooo D_what about understanding that people are usually expected to act differently with someone they've just met then with afriend or family member? 25. Copies appropriate behavior of others when: D. whatdoes heishe do when heisheis in 26, Adjusts behavior to keep from disrupting others nearby (for example is quiet near others who are working, listening to show, ete.) ped O ‘D. what about realizing when he/she needs to adjust his/her behavior so that he/she doesn’t disturb others nearby, like someone whois working oF listening to a show? with someone new than witha friend or fa anew situation and unsurehow to act. ] sre how 2100 ew si irprizeceie ATERVIEW TOPIC |: CONVERSATIONAL SKILLS | lagested interview Queston: Who does [name] have conversations with, and what are his/her conversations like? | "27. Moves easily from one topic to another in conversation when needed; does not “get stuck” on one topic. feo D How flexible is he/she at moving from one topic to another in conversations? 28, Stays on topic in conversations when needed; docs not: _D_whavabout staying on topicin conversations, rather than 29. Provides additional explanation when needed in order for someone to follow what he/she is saying (for example, “Incase. ‘you missed what I ssid..." *What we were talking about wa..." cao ing when someone he/she stalking with needs some background information or something inorder to follow what's being said? 2100 ATERVIEW TOPIC J: TAKING OTHERS’ PERSPECTIVE lagested interview Queston: What are some things that [name] does that show that he/she is thinking about the other person's point of view, like what they think, want, or are interested in? 30. Recognizes chat the ike and dake of others can dfer from his/her own lr example, might say “Kelly Tikes pizza, | bbut I don't; “Tliked that movie, but Gretchen hated it”) Q 2100 How well does he/she realize that other people might not ike and dstke the same things that he/she does, for example, movies orkinds of food? Si Sa Saneadocr ies cel ings nti tan Go cas lemony by bringing up something thathe/she knows thatthe other 2 1 0 [1 D How often does heshe start a conversation with someor person interested in? 32, Participates in conversations on a topic not of incest to him/her. bootel D what about taking with others bout things that they're interestedin, even though he/she really isn't? 33. Willengagein activities suggested by friends, even if aot preferced. 1 the respondent has not had the opportunity to observe this, estimate a score and check the Estimated box. D to 2100 Vinelnd-3 Banainer! nein ermResponse Options: 2= Usualy, 1=Sometimes, 0= Never TT NTERVIEW TOPIC K: OBEYING TIME LIMITS uageste tei Question: How is [name] about following time limits you give him/her and letting you know about " his/her plans when he/she goes out? 7a, Fallows time Tims imposed hy parent or caregiver forevample, amount afime allowed vo watch TV, playa game we the Interne, o play ose). Score 2th individu dd hs when younger buthes now outarown it meal O D When youtelthimvher that he/she only allowed to do something fr slinited amount of time, how often does helshe boy ha tietnt thot having tobe omnes Youcan ath Vannes rans then Youve 35. Informs parent or caregiver about his/her plans when he/she gos out (fo example, what timc he/she leaving and returning, where he/she is going) 1 score 21th india i hs when younger buthas now outgrownit D_ what about telling you about his/her plans when he/she goes out, like where he/she is going ome? NTERVIEW TOPIC L: GULLIBILITY uggested interview Questor: What does [name] understand about different ways that people might try to take advantage of him/her, and what does he/she do to keep from being taken advantage of? Ser Uaersands thata friendly appearing person mayacrallyinvend harm (7) D whatcoeshe/sne understand about how aftiendly acting person may actually want totake advantage of hiner? _ "37, Isaware ofand uses caution when encountering risky socal situations for example, Internet solicitations, a stranger’ offer oF aide or money, “binge” drinking partes social media, personal ads). : 1 Ifthe respondent has not had the opportunity to observe this, estimate a score and check he Estimated box. 2100 | D tows he/she at being cautious when people he/she doesn’t know well try to get him/her to do something risky, either inperson or through the internet? 438. Recognizes that advertising messages may not be accurate. D_ What about understanding that the purpose of advertising isto influence Tnn'talwaye totally true? iedecisions,andthateverythinginads = 2 1:0 O) 39. Thinks through the consequences of his/her actions before acting (for example, refrains from acting impulsively, considers relevant information). 2100 D tow often does heshe think though the consequences before doing something? 40. Avoids being manipulated, dominated, o taken advantage ofby others. feo @) what doeshe/she dot keep others from controling or taking advantage of him/her? NTERVIEW TOPIC M: DOING THINGS WITH PEERS ‘gut are ues Hepeoen dons hase wegen wth ory Rafter enwentrer do they deand who ienekt “41. Gocs places with peers during the day or evening with someone supervising (for example, shopping, amovie, sports event). Score2 fhe individ de this when younger, buthas now outgrown theneed tobe supervised 2100 ___D. what places does helshe go with thers hisher age with someone supervising, either during the day or at night? 42. Goes places with peers during the day without someone supervising (for example, shopping mall, park, ‘community center). 2100 D. what paces does nelshe god 43. Plans ahead to do things with peers on his/her own. Hf 2100 D what kinds of activities does he/she plan ahead with othershis/her age? mn for movies, sports events, concerts, etc, (for example, looks at a newspaper or on the Tncernetphonesa movie thea). 2100 © whatabout looking up schedule information for movies sports events, concerts and so on? 48. Pans fun activ =) D inat stout octviies that require oto things tobe planned iaa birthday party or grow outing? zaeg 0 Vineland-3 Domaine ineniewfam 11 ies with more than two things to be arranged (for exemple, biethday party, group ouResponse Option INTERVIEW TOPIC A: RUNNING AND WALKING. co ‘Suggested interview Question: Tell me how [name] runs, and how far he/she walks by himself/herself. a 1. Runs smoothly without falling D stow smoathiy dows helshe rn, ane how afte zag O "2. Runs smoothly, changing speed and direction (for example, when playing tag or sports, or chasing a pet). et ©. How about changing hisiher speed and direction white running, ike when playing tag or sports? 3. Walks two or more blocks without having ro rest or nceding physical support. TD. What about walking two: INTERVIEW TOPIC B: USING STAIRS Suggested interview Queston: Tell me how [name] goes up and down stairs. 4. Walks up stairs, aleernating feet; may use railing, How does he/she goup stirs? 5. Walks down stairs alternating fet; may use railing. D How does heishe go down stairs? 6, Climbs alight of eight or more sary ata normal pace; may we rlling © Heir tetdotshatia soups 2100 eee Cl go CO INTERVIEW TOPIC C: GRIPPING AND TWISTING Suggested interview Question: Opening a door with a doorknob or unscrewing ajar lid require us to grip and turn our wrist. What kinds of things does [name] do that require gripping and twisting? 7. Opens doors by turning a doorknob or handle. D what about opening doors by turning a doorknob or handle? 8. Unveraps small objects (for example, gum or candy). @_ How often does he/she unverap small objects lke a plece of candy or gum by himself/herself? 9. Uses a ewisting hand-wrst motion for example, winds up a toy or music hex, serews/unserews the id of ate) D whataboutholding something n onehand and twisting withthe other, Ike winding up atoy or musicbox, or 2100 screwing the id of INTERVIEW TOPIC D: DRAWING AND COLORING Saggested interview Question: Tell me the kinds of things that [name] draws or colors, 10. Holds crayon, pen, or pencilin prope position (that is, usinga tripod grasp, not with fist) for writing or drawing 2100 1 helshe hold a crayon, pen, of pencil? 11. Drawsa circle freehand while looking at an example, elo . Drawsa straight line using auler or straightedge, ff 7 Dhar snout drawing astraightine sing ruler orstinghtedget gee O 15. Colorsa full-page drawing or scene using two or more color; all eoloring is inside the Lines & Score2ithe individual ei is when younger but has now eugrown coloring, 2100 D_what kinds of things does he/she color, and how much cok 12 Vineland-3 DomanLve interven Frm prrezeaeieCee Response Op NTERVIEW TOPIC E: RIDING A TRICYCLE OR BICYCLE ont ‘uggested interview Queston: Tell me what name] is doing in terms of riding a tricycle or bicycle. a 14, Pedals tricycle or other three-wheeled vehicle for atleast 6 feet. Score 2 the indikdual did this when younger but has now ovtgrownit 2100 D How fardoes he/she pedal a iyele or other three-wheeled vehicle? 15, Pedalsa tricycle orotherthree-wheeled vehicle around corners 1 Score2if the individual did this when younger, but has now outgrown it. 2100 D whataboutpedating atriycl or other thre-wheeled vehicle around corners? 16, Rides aalanc ike orbicyle with raining wheel for atleast 10 fee, score 2 fhe nivialddhs when youngest hs now outgrown 2100 @ vom far doesbalsharde balance ble ora bce with ralning weet 17, Rides a egularbicycle without training wheels without falling. Peo NTERVIEW TOPIC F: CATCHING A BALL ‘uggested Interview Question: What size balls does [name] catch, and from how far away? 18, Catches abeach ball-sized ball from at least 6 fet away D whataboutad ball thrown from 6 2100 19, Catches tennis-o baseball-sized ball from a distance of2 or 3 feet, using one or both hands extended away from body. D_ whatabouta tennis: or basebal-sized ball thrown from? or 3 feet away? 2100 Cash oral itl fom ads fale ft evga Fae ee D__ What about a tennis: or baseball-sized ball thrown from 10 feet away or more when helshe needs to move to catch it? NTERVIEW TOPIC G: USING SCISSORS ‘uggested interview Question: Tell me how [name] uses scissors. Di. Ues sso oct alongastagh line crows atandard set of pape D How er eaiey C1 DB. Cars out simple shapes les, squares, rectangles ee). D whatkindsofthings doeshashe cutout? 2100 elshe cut with scissors ona straight line across a sheet of paper? 23, Cuts out complex shapes (for example, stars, animals alphabet eters). 200 D__whatkinds of things does heishe cut out? NTERVIEW TOPIC H: TYING ‘uggested Interview Question: How often does [name] tie a knot or a bow without help? 7, Ticss knoe D uhatabouttyingatnot without help? ee 25. Ties secure bow (or example shoe laces, gift wrapping). Ped o D_whatabouttying a secure bow withouthelp for example, shoe aces ora git wrapping bow? officeuseonly BREN +25 x 100 = est | MOT Ran score Vineland-3 Domaine ienien fam 13AALADAPTIVE BEHAVIOR DOMAIN Jalike the adaptive behavior items that you have just completed, che maladaptive behavior items are read directly to the respondent. ‘ead or paraphrase) each item as itis written, clarify if needed, andl ask che respondent to tell you how often the behavior happens: | = Often, 1 Sometimes, 0= Never UGGESTED INTRODUCTION ay to the respondent, “We're going to finish by talking about problem behaviors that [name] may or may not be exhibiting. This time I'm going to read tua description of each behavior and ask you to tll me fit heppens often, happens sometimes, or never happens.” Mens CITE) Response Options: 2= Often, 1 = Sometines, 0-=Never “i Bair ovedy wendy or genteat (ir camper onlay ron vlna iniba dose taeed Wy clngres pa orveaceel EBRD : SS eae 7 U0 3. Has sep problems (fr example, walk in hisyher sleep has alot ofnightmares, eps way more orles than others a oO his/her ag). a a 7. Refit to goto school or work, or has to come home, Because of worrying, sadness, nervous, ee, to Rutcarasee eee : eo 6. Cries ors ad for no lear eason, moO 7. Avoids interacting with others (withdraws, prefers to bealone,ete). ey 100 8. Lacks fret doing hing hat ee ej ore eno. oo 9. Teertemey earl of one or more common eet or swans example eights snakes, leat) oO aT Won vm TE a Eres aa io O Fiz Sea aplasia roo ee ee a ro Sn Tao 1, Has temper tantrums: Sereams, cries, kicks, ete 3. Bullies others phys 4. Lies cheats or teal 7. Isverballyabasive hat is harsochers on purpose with insults, pur-downs, ct). ', Breaks rules or laws because of peer pressure. 9. mach more avo renee than therfore 2 LL Destroys his/her own or someone else’ possessions on purpose. 2 ~_-Externallzing fan Sore 4} Winelané-3 Domair-ee tern form eer ieaerereas Ea Response Options: 2= Often, 1= Sometimes, 0=Never “i 41, Gets fixated on objects or parts of objects for example, stares at spinning wheels or fan bladss, lines up object, lips light switches over and over). p10 0 2, Talks about hearing voices tat others do near, or ecing things that others donot see. roo 3 Hanns himself Gor ample tangs here iors ules tsi pallet hiverha). 2-10 4 ho ony rc scan swith inl enclinpuic sayings harmakem® 9G] 1: Repent phys motemens aver and ver (rename ok akan ath pi Maps and) 2100 & Bats non-food ome ouch an dit pet or ay "7. Gass fatedon parte opiethar annoys orem einai, map aby ems “210 D 8. Talks about killing himselO/erself oc has tried o kills oof “9, Wanders darts away, or takes off from home, school, o someone watching him/her without A o 20 Tora oharturLlsomeonas a f 20 O "Hh Inicked by others into doing something thu couldsedoulyharmhimorheyervmenecse —SCSCS*~*~*~*~S~Sis~aC GENERAL COMMENTS {Use this space to record any general comments about the interview that you want included in the test record. Vineland-3 Domaine ineiew frm 15Vi nel an d-3 Domain-Level Interview Form Score Report Yer Month = Day Examinee’s Name: Test Date Examiner's Name: Birth Date Interview Respondent's Name: TestAge Score Summar) EEE Eee | TEMES Pee LENT ' coe Faw Standard 85% 90% 95% Percentile Score Score Confdencelnieral Rank Bt Communication (con) A Dally Living Ski (ots) Socialization (s0¢) J Sum of Domain Standard Scores ‘See Table 83 to convert ABC [Adaptive Behavior Composite “aso Pe kaw Sale Score __ Score tic ems (Circe all tem sores of 20 a 2 i 2 By 10. Internatizing 1 1 1 1 a 2 a 2 BI 5, a) nL. Externalizing saw Caleltin of Mean Domain Standard Score Te egaenin Wane = Gara ede ooyght ©2016 NCS Pearse, ne A gts eserves. Srey 23486769101112 BCDE. Pruct Number 3323