Student’s Name:

Person(s) Responsible:

Goal & Criterion:

Objective or Benchmark:

Timeline for Completion/Days Conducted:

Environment:

Activity:

Data Collection Method:

List only those steps of the activity that will provide data that verifies whether the goal chosen has been reached.
Use the following key to collect data on the student’s performance for the steps chosen.

(+) for independent performance or with use of identified support or prompts in each step

(+/-) for emerging

(-) for nonperformance even with use of support or prompts in each step

STEPS

DATES

..........................................SUPPORTS OR PROMPTS................................................. .

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.