Home Observation Card Form
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1
2Module 3a
Handout 3a.4: Individualized Intensive Interventions
Home Observation Card
Side 1
Child’s Name: ________________________________________ Date/Time: ______________________
Activity: _____________________________________________ Observer: _______________________
Describe Challenging Behavior:
What Happened Before?
Told or asked to do something
Playing alone
Changed or ended activity
Removed an object
Moved activity/location to another
Object out of reach
Not a preferred activity
Told “No”, “Don’t”, “Stop”
Child requested something
Difficult task/activity
Attention given to others
Other (specify) ___________
What Happened After?
Given social attention
Punished or Scolded
Put in “time-out”
Given an object/activity/food
Request or demand withdrawn
Ignored
Removed from activity/area
Request or demand delayed
Given assistance/help
Other (specify) ______________
Purpose of Behavior:
To Get or Obtain:
To Get Out Of or Avoid:
Activity
Attention
Activity
Attention
Transition
Object
Food
Object
Food
Person
Place
Person
Place
Help
Other (specify) ________
Demand/Request
Other (specify) _____________
Home Observation Card
Side 1
Child’s Name: ________________________________________ Date/Time: ______________________
Activity: _____________________________________________ Observer: _______________________
Describe Challenging Behavior:
What Happened Before?
Told or asked to do something
Playing alone
Changed or ended activity
Removed an object
Moved activity/location to another
Object out of reach
Not a preferred activity
Told “No”, “Don’t”, “Stop”
Child requested something
Difficult task/activity
Attention given to others
Other (specify) ___________
What Happened After?
Given social attention
Punished or Scolded
Put in “time-out”
Given an object/activity/food
Request or demand withdrawn
Ignored
Removed from activity/area
Request or demand delayed
Given assistance/help
Other (specify) ______________
Purpose of Behavior:
To Get or Obtain:
To Get Out Of or Avoid:
Activity
Attention
Activity
Attention
Transition
Object
Food
Object
Food
Person
Place
Person
Place
Help
Other (specify) ________
Demand/Request
Other (specify) _____________
The Center on the Social and Emotional Foundations for Early Learning
University of Illinois at Urbana-Champaign
csefel.uiuc.edu
H 3a.4
Rev. 5/06
(p. 1/2)
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