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AAC Questionnaire
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  INTERACTION CHECKLIST FOR AUGMENTATIVE COMMUNICATION INCH Communication odes Description Key () Strategies Scoring Key ;:: L Linguistic (verbal language skill) VI () + Present (effective without prompts) :; PA Paralinguistic (nonverbal vocalizations, inflection) () ( ) () :';i Emerging (needs prompts, inconsistent) J: VI ;:: :';i VI K Kinesic (facial expression, body movement, gestures) z w Absent (or not observed) tD w VI () Z :; :::; w z PR Proxemic (physical positioning and distance) « i >< 0 / Not applicable z ' ) ' w 0 ' w « C Chronemic (timing and rate) z « z ' J: ' w :::; 52 () S; .. - VI I;j;;;~lr((f(~;; (gY:J[s( S8H7i·. ( ã · ·f i. ,~~;~trz1$il z K1j~1i;ft~fgfl Iff:. . ;;:c,,(~;flr J 1<:(. r}';f iã ;jl~[i:~;f;:. .f f X i ', ... .(.f. .. <; (. fic. i i. q:ef;r:;; Hi{ ( ã (,h*)i ã :,': 11. it 1.0 INITIATION page 7 of manual L PA K PR C S W . 1.1 Responds to greetings from others , 1.2 Gains partner's attention i , i : , 1.3 Uses social greetings I I I i 1.4 Introduces self when appropriate I ã 1,5 Ask questions to initiate conversation , 1.6 Establishes topic consistent with situation I n k{·~;%?;~;·tH~Hff: i ii. f ',;(, f f ;~t.t;40~ If2'; I~~ ra~~ ;~l I :;EJ i~~1~i~lit;i~ l;j f ii f)~; i;' ,i' if, 1.'( ,.:(, 2,0 FACILITATION page 10 of manual L PA K PR C S w 2,1 Uses eye contact to indicate attention to partner i I 2.2 Maintains optimal physical distance from partner i . i 2.3 Positions self to enhance communication I f ã 2,4 Uses AAC system without prompting , 2,5 Seeks help when needed . 2.6 Gives partner instructions when necessary I 2.7 Uses shortcuts whenever possible i ?R I k n lit inl fnrm' I  --   ,---   .. .. 2.9 Maintains topic consistent with situation 2.10 Shifts topic smoothly 2.11 Uses pauses or spaces for greater clarity 2.12 Defines sentence types 2.13 Uses linguistic forms to clarify time frame I~}~;r,; .i,/.J · · ·H'jN.§J Jf;\{;))'c;: rJ~ij./JTijBN.r, ã i.;.;,. 3.0 REGULATION p ge 15 of m nu l 3.1 Maintains partner's interest and monitors understanding 3.2 Gives feedback to partner 3.3 Restates message when necessary 3.4 Adds detail; expands on message 3.5 Adapts vocabulary appropriate to partner's needs 3.6 Adjusts rate of production 3.7 Adjusts volume of e system as appropriate 3.8 Keeps trying; persists; repeats if necessary 3.9 Alerts partner that more time is needed to finish message t.l :;~5£'· §J;f f'f:W%, g~~··· ·j·· . h.;; .. / , ; , . .,. ã ?' ,,,;;.g'gif ~'X;'I' ;/'c ,/i,; ·'.d ·'iii. ,,;., .. . ,.;, .;;. 4.0 TERMINATION p ge 19 of m nu l 4.1 Uses social farewells 4.2 Recognizes need for topic closure 4.3 Stops composing when partner indicates understanding 4,4 Indicates when finished with conversation . . .:. .' ,. . . , ·}U.,i , (i;,' /; ., ; . f; . ; .. ' ;; I. .'  /. .f J...) (t;.,;: .. L; .. l t~I~. Copynght © 1984, Imaglnart Communication Products, Revised 1991 All Rights Reserved I I I I : : : I i I I I I I I I i I .ã I I I I I I I I I I I I I I I I I I I Iii ei; tii tifi. ~lt rJ,iU1t'.; J, ,. ·'} ,2Ifj~,;f$~t~'tiSFi:;,.t:r'if.ii i.F i'Ji· ·'i}~i;'t I'~ ' ~H L , PA K PR C 5 W ã I I I I i I I i I I I I I -1 I I : : 1 I j i I I I I \ I I I I j I I I I I I I I I I I I I I I :Cf:, lift . ,.i f, } N' M,i~ ;~;.NWhl.','.fi.tG' ?~',i·,fif3tt1~;i,il ,,~I{;~t ~<. ;.,. · ·X ,. ã. tyt 'Ut'. .; '·i· ; 7« ;.:I , ;,i, / . ; f;, i 1;3]5 L PA K PR C 5 W I I I I I I I I I I I I I I I I I i,i/: .i ·· ,. '. i:: .,, . . . ; ·······,i' ...., ......ã ' i , 'f ,'> i/:},N;tffii.i;(,SlfH;; , L.;i.<: ; ; :. ;'. ',. ; ... .iIT' 9/95    Worksheet Summary Present level of unctioning Strengths Weaknesses o 6 Initiation Strategies o 3 Facilitation Strategies o 9 Regulation Strategies o Termination Strategies Intervention Plan Target Strategy ode Context What ow Where With Whom  INTERACTION CHECKLIST FOR AUGMENTATIVE COMMUNIC TION INCH An Observational Tool to Assess Interactive Behavior Revised Edition SUSAN OAKANDER BOLTON SALLIE E DASHIELL NAME OF AUGMENTATIVE SYSTEM USER: D.O.B.: OBSERVER: DATE(S): DESCRIBE AUGMENTATIVE SYSTEM(S) USED: DESCRIBE THE USER S PHYSICAL POSITIONING AND MOTOR SKILLS: DESCRIBE THE USER S COMMUNICATION CONTEXTS (ENVIRONMENTS AND PARTNERS): Home Educational Vocational _ ommuni~ ENTRY SKILLS FOR COMMUNIC TION INTERACTION USING C SYSTEMS Skills Present Emerging Absent Comments Demonstrates desire to communicate Indicates physical state and emotion Establishes eye contact Communicates using nonverbal modes Uses symbolic representational forms Demonstrates motor operation of aids
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