\ Functional Communication Assessment: Informant Interview sos ‘Adapted with permission fom Project QUEST mservice Manval (aco etal. 1980) Ghié’s name:__N i Ko Tey age: 1-0 ______ Dare; _ 3+ 10-14 Interviewer: Informant: _Li¢h NI agu Relationship: _ 4.01 t Directions: The following questions are designed to obtain information about the ways your chil communicate The information wil be wsed to evelop the most appropriate communication proprem for your cid, Please answer each question thoroughly. Add information wherever you want. iis most helpful 0 96%, ‘many examples as possible and to add details, such as, “He is ust starting to do this"; "He used to do 17 1, “He does it only when 1 tel him to dof.” Add information to describe how often and how hard you hid tres to communicate and how sificuit itso understand. Also note whether your child looks you when tying to communicate. EXPRESSING FEELINGS, How do you know when your child: 1. Ukes an activity, food, or other? _ Petar is peessias oe be Seeker benny ont, moles chris Hirm pridwrer , grins, claps 2. Does not like an activity, food, oF other? al leawes tue orn. 3. Feels good or happy? | 5, Cin vig, compas ue 2 down 4. Feelsllor in pain. Laviak oyoressa ms Lok guew Slaypw om pyta. Ofen a vacouck |pple-in bt . 5. Ishungy? se mm _t sc. fp poly 6. Is uncomfortable? inbead - of look dus Lupe 7. tsanvious or afin AM AS IS Gr ailov by above — Jocabizal'os \nxtds bin bead gal tonsg beodl istehe oWaid - hell step bnacl wide eee nati vans Cub 000 by Hard ance an ke sen, man fi are rn aca Fanny Tat A eH mma. Pan traapt on Wasa atn o Payson Comore VS00 22732 AH GTONOASIOFORM 63 (page 20f 19) REQUESTING How do you know when your child: 8 wansatenion He's a pest = comes $ Sluts boob [rw Aendig ioill Say "Come St wae te 4 ine ow puter POL ips We wr nc. With ovnnpag angle hee t 9. Wants more of something? Li $1 alle ol ru Woihe peowp bis ill a" Aawrve* om taller, butawsl sprnta acest lay 10. Wants you to continue an activ (for example playing a game or rocking? Aygeoty 4s WA te eeshin Uv 11, Wants you to stop an actnty? Hef sec “atl dime "See yr later” U v 12. Wants you to start a familiar routine (for example, fixing a snack or playing peek-a-boo)? Nj 13, Wantsheip? ite" bring snmehucg | her asked be ll as tod tel ber Cay yer bly me 4a, ee d Asts oe theowe om (us tebber 4b, Wants something to ink? Ces lumsel€ a drmle 15. Wants a certain object? WU teh will aah om device, or gets ot lon elf Wants to do something? When UA ed wohak de vm want bell rtspereh wih Chan Lele Wer pad mdevee 16. 17. Wants to use the bathroom? ash goes. oy will om bacle of lerpats will anower yes ome whan 4 sled 18. Wants affection? _GYHts ond 51} “ ved fo cnee § Sth a he) (continued) ep © 106 wy are aan an ice dra, ute ot Man MA ie Jose Fry Trt A pn see ‘matey Py Sek aon» ene Ta appeal Capers isan oieFORM 63 (ape 3 of 10) REQUESTING (continued) 19. Does your child make a choice between several objects when the objects are presented or in ew? —___ Deserbe, Yes - Ui Me, ches byrks, ipad er p yorsnns hats, Srors thofu,, feud choir. 20, ees our hd mate caer ane se ace? oecte Yor crevices! wale!er' bile! worm! clepses feshurants fro tly, Platte foro, muni by histen to, Prod fe cot a. Does your cid make a chic of an objector actty when the pose selections are nat presente or in vew? Describe._Aiw, 1 nso Wits vitwale, more hae oloyects 22. How do you know when your chid doesnot understand something that someone has sid? Hic aespene bine Dos your chk sk fr ation by sg, Wo db undead orby doing somevingite 4 selftbiting?_NV2__ Describe. 23a, Does your child ask for information (fr example, where someone is, where someone lives, or when a birthday ‘or holiday wall occur)?_AVe___ Describe. 23b, Does your cid ask the same questions repeated? _ Vo 273e. Does your child ask for one thing but appeer to want something diferent? Yea Describe ll oben ones” Ie _ladicste gage tod lie wants uf di ov fur Serve ps on fetler PROTESTING Haw do you know when your child: 24, Does nat want to do something or wants to stop doing something? Describe. He'll 5 Yall clewe" um frcther Ww" Se ye Later “ ' Cpr © 198 by Manda Jann ase sunen Dann tMan Ma sae Ean Fare Yom /At pe a PSL Try Gi aon a Sean Tn Papal Crp aObeabTae/ (an Gross