Module 3 DSM-5 Checklist | ID: _____________________ Date: ____________________ Age: ___________________ Examiner: ☐ Parent/Caregiver ☐ Therapist

Language Level: A1. Overall Level of Nonechoed Spoken Language: _________

BOSA Version (please circle one): PSYF F1 F2

DSM-5 Checklist for Module 3
A. Impairment in Social Communication & Social Interaction B. Restricted and Repetitive Behaviors
ADOS Recode BOSA Parent Other ADOS Recode BOSA Parent Other
1. Deficits in Social-Emotional Reciprocity 1. Repetitive and Stereotyped Behavior
Score Rule Score Report Info Score Rule Score Report Info
0→0 0→0
vA5. Offers Information A2. Speech Abnormalities Associated with Autism
1-2→1 1-2→1
0-1→0 0→0
vA6. Asks for Information A3. Immediate Echolalia
2-3→1 1-3→1
0-1→0 0→0
*A8. Conversation *A4. Stereotyped/Idiosyncratic Use of Words or Phrases
2-3→1 1-3→1
0→0 0→0
*B4. Shared Enjoyment *D2. Hand and Finger and Other Complex Mannerisms
1-3→1 1-3→1
0→0 0→0
*B7. Quality of Social Overtures D3. Self Injurious Behavior
1-3→1 1-2→1
0→0
B8. Amount of Social Overtures/Maintenance of Attention Other (Specify):_______________
1-3→1
0-1→0
*B9. Quality of Social Response 2. Excessive Adherence to Routines and Ritualistic Behavior
2-3→1
0→0 0→0
*B10. Amount of Reciprocal Social Communication D5. Compulsions/Rituals
1-3→1 1-2→1
0→0
(B5 from M4). Communication of Own Affect Other (Specify):_______________
1-3→1
Other (Specify):_______________ 3. Restricted, Fixated Interests
0→0
2. Deficits in Nonverbal Communication used for Social Interaction *D4. Excessive Interest or Repetitive Behaviors
1-3→1
0→0
v*A9. Descriptive, Conventional, Instrumental, or Informational Gestures Other (Specify):_______________
1-3→1
0→0
(A10 from M4). Emphatic or Emotional Gestures 4. Hypo- or Hyper-reactivity to sensory input or unusual sensory interest
1-3→1
0→0 0→0
*B1. Unusual Eye Contact *D1. Unusual Sensory Interest in Play Material/Person
2→1 1-3→1
0→0
*B2. Facial Expressions Directed to Others Other (Specify):_______________
1-2→1
0→0
B3. Language Production and Linked Nonverbal Communication Other Behaviors (E Codes)
1-2→1
ADOS Recode BOSA Parent Other
Other (Specify):_______________
Score Rule Score Report Info
0-1→0
3. Deficits in relationships E1. Overactivity
2-3→1
0-1→0 0→0
(B15 from M1). Level of Engagement E2. Tantrums, Aggression, Negative or Disruptive Behavior
2-3→1 1-3→1
0-1→0 0→0
v*A7. Reporting of Events E3. Anxiety
2-3→1 1-2→1
0-1→0 Note: ADOS Score: 0-3 from protocol; BOSA Score: 0 or 1 (absence vs. presence); ADOS ratings of 7, 8, and 9 should
vB5. Comments on Others' Emotions/Empathy
2→1 be converted to N/A for the BOSA Score; Parent report: P if symptom reported in parent interview; Other Info: P if
0-1→0 symptom present based on additional gathered or observed information.
vB6. Insight into Typical Social Situations and Relationships
2-3→1 *Indicates ADOS-2 algorithm items; vConsider an 8 code if not sufficient evidence to code 0-3
0-1→0 Clinical Notes on Observations or Outside Information:
vC1. Imagination/Creativity
2-3→1
0-1→0
v(B8 from M4). Responsibility
2→1
Other (Specify):_______________

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