Initial Student Assessment – Beginner

Date: Student: DOB: Age:

!រចូលរួម (Attending) េធ្វើ្រ-ប់-ម (Imitation)

!រអង្គុយេស្ងៀម(Sitting) Y/N េចះេធ្វើ្រ-ប់-មចល9ធំ(Gross motor im – Y/N
GMI)
សំឡឹងមុខចំ (Eye Contact) Y/N េចះេធ្វើ្រ-ប់-ម េ្របើវត្ថុ (Im with objects) Y/N
េឆ្លើយតប េពលេEេFGះ (Reponds Name) Y/N េចះេធ្វើ្រ-ប់-មេ្របើ blocks (Imitation with Y/N
blocks)
យកចិត្តទុកLក់ ចូលរួម (Joint Attention) Y/N េចះេធ្វើ្រ-ប់-មចល9តូច (Fine motor Y/N
imitation)
ដឹង អ្វីតំបូង អ្វីប9Oប់ Y/N េចះនិQយ-ម១Sក្យៗ( Verbal imitation ) Y/N
Visual Performance េចះេធ្វើចល9Vត់-ម (Oral motor Y/N
imitation)
េចះេរៀប-មរូប ( Puzzles) Y/N
េកៀប-មពណ៏ (Pegs) Y/N
Lក់រូបShapeចូល្របអប់ -មរូបZង(Shape Y/N !រេស្នើរសុំ (Requesting)
sorter)
េរៀបែខ្សអង់!ំ (Beading) Y/N េចះចង្អុយ េដើម្បីសុំ( Pointing) Y/N
`ត់ពណ៏aមួយ !លរេទៀន (Color with Y/N េចះេ្របើSក្យ១Vត់ៗ េដើម្បីសុំ (Verbalizing) Y/N
crayon )
Matching េចះេ្របើរូប បbcញ េដើម្បីសុំ (PECS) Y/N
កំនត់េe វត្ថដ
ុ ូចfg (Identical objects) Y/N េចះេ្របើ សh្ញ េដើម្បីសុំ (Sign) Y/N
កំណត់េe រូបjពដូចfg (Identical Y/N
pictures)
ផ្កូផ្គង វត្ថុេnរូប ដូចfg(Objects to pictures) Y/N ជំ9ញយល់ក្នុង!រ pqប់ និងេធ្វើ-ម (Receptive Language Skills )
ផ្គូផ្គង រូបេnវត្ថុ ដូចfg(Pictures to objects) Y/N េធ្វើ-ម ១តំrក់!ល (Follows 1-step dir) Y/N
ផ្គូផ្គង ពណ៏ ដូចfg(Colors) Y/N psល់ ែផ្នកZង!យ (Id. body parts) Y/N
ផ្គូផ្គង Shapesដូចfg Y/N psល់ វត្ថុឬរូប (Id. objects/pics ) Y/N
ផ្គូផ្គង អក្សរ ដូចfg(Letters) Y/N psល់សVជិក្រគvpរ (Id. familiar people) Y/N
ផ្គូផ្គង េលខ ដូចfg(Numbers) Y/N េចះចង្អុលរូបក្នុងេសៀវេw(Point to pic in Y/N
book)
កំណត់វត្ថុមិនដូចេគ (Non-identical Y/N ជំ9ញក្នុង!រ េ្របើSក្យេដើម្បបbcញ (Expressive Language Skills)
objects)
កំណត់វត្ថុ xក់ទងfg (Assoc. objects) Y/N psល់ អក្សរតំrង វត្ថុ (Labels objects) Y/N
Intraverbals= basic conversation skill psល់អក្សរតំណង រូប (Labels pictures) Y/N

Page 1 of 11
បំេពញក្នុងចេ9yះ (Fills in blanks) Y/N Self-Help Skills
សំណzរសង្គម (Social questions) Y/N េចះេLះែស្បកេជើង (Removes shoes) Y/N
សំេលងសត្វ (Animal sounds) Y/N េចះេLះេ្រpមេជើង (Removes socks) Y/N
េចះ្រpតេ{ (Removes pants) Y/N
េចះេLះ|វ (Removes shirt) Y/N
Play }នេរៀនចូលបង្គន់េe?(Is toilet trained?) Y/N
psល់មុខb វត្ថុេលង(Functional toy play) Y/N
េចះេលង~ក់េអើ (Peek-a-boo) Y/N
psល់េវន (Turn taking) Y/N

Reinforcement (circle all that apply and write specifics):

1. Food 6. Video games
2. Drink 7. Physical touch
3. TV 8. Toys
4. Youtube 9. Social Praise
5. Tablet apps

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 Initial Student Assessment – Intermediate

Date: Student: DOB: Age:

!រចូលរួម (Attending) Intraverbals

!រអង្គុយេស្ងៀម (Sitting) Y/N េចះេ្របើសំនួរសង្គម (Social questions) Y/N
!រសំឡឹងមុខចំ(Eye contact) Y/N psល់សំេលងសត្វ (Animal sounds) Y/N
េឆ្លើយតបេពលលឺេFGះ(Responds to name) Y/N េចះេឆ្លើយ សំនួរ ែបបWh ក្នុង្របេQគ (Wh-qu re: Y/N
sentence)
យកចិត្តទុកLក់ (Joint Attention) Y/N េចះេឆ្លើយ សំនួរ ែបបWh ក្នុងរូបjព (Wh re: Y/N
picture)
េមើល-មចំនុចអ្នកចង្អុល (Follows a Point) Y/N េចះេឆ្លើយ សំនួរ ែបបWh ក្នុង្រប€នបទ( Wh re: Y/N
topic)
េមើល-មែភ្នកអ្នកេមើល (Follows Eye Gaze) Y/N |ចេឆ្លើយេe្រពឹត្តិ!រ}នេកើត (Recalls events) Y/N
Imitation
្រ-ប់-មចល9តូច (Fine motor imitation) Y/N
្រ-ប់-មចល9ធំ ២តង់ (2-step GMI) Y/N
្រ-ប់-មវត្ថុ ២តង់េឡើង (2+ step im with obj) Y/N Social
េធ្វើ-មរូបក្នុង ប្លក់ (Block imitation) Y/N សុំជំនួយពីមិត្ត (Request from peer) Y/N
Receptive and Expressive Language ្រ-ប់-មមិត្ត (Imitates peer)
េធ្វើ-ម២ជំƒន (Follow 2-step instr) Y/N ្រ-ប់-ម !រែណ9ំមិត្ត(Follow peer instruct) Y/N
េចះហុចឪ្យវត្ថុ ២ (Gives 2 items) Y/N អក្សរតំrងឪ្យមិត្ត (Label for peer) Y/N
េចះកិរិQaមួយរូប 3D (Verbs – 3-D) Y/N េចះp‡គមន៏មិត្ត (Greetings) Y/N
េចះកិរិQaមួយ 2D (Verbs – 2-D) Y/N េចះចូលរួមសន្ទ9 (Statement/statement ) Y/N
psល់វត្ថុជុំវិញខ្លួន (Env’t objects) Y/N ទស្សន៏xយ វត្ថុ (Guess what) Y/N
psល់សVជិក្រគvpរ (Familiar people) Y/N Statement/question Y/N
េរៀនពី បន្ទប់ (Rooms) Y/N Requesting
េរៀនពី ទីកែន្លង (Places) Y/N េចះេ្រជើសេរីសជេ្រមើសល្អ(Makes a choice) Y/N
េរៀនពី មុខb វត្ថុ (Function objects) Y/N េចះេឆ្លើយ Yes/no Y/N
េរៀនពីមុខbរ បន្ទប់ (Function rooms) Y/N សុំរបស់aមួយ ‹y(For item w/ phrase) Y/N
េរៀនពីមុខbរ ទីកែន្លង (Function places) Y/N សុំជួយ េបើក (For help, open) Y/N
psល់ពីមុខbរ ែផ្នកZង!យ(Function body Y/N Others to perform action Y/N
parts)
psល់ពី€តុផ្សំៃន វត្ថុr១( Features) Y/N េចះេឆ្លើយ េ`qត|រម្មណ េពលនិQយŽ look (For Y/N
attn: “Look”)
េរៀនពី ្របេភទៃនវត្ថុ (Category) Y/N េចះសុំេLយេ្របើ សំនួរ Wh (Wh-questions ) Y/N
េរៀនពីបុគ្គលិកលក្ខណៈមនុស្ស (Attributes) Y/N Verbal Imitation
េរៀនពី ទី-ំងវត្ថុ in/out/top/under Y/N េធ្វើ្រ-ប់-មលំេលង (Sounds) Y/N

Page 3 of 11
(Prepositions)
េរៀនពីលំLប់របស់ ្រពឹត្តិ!រណ៏(Sequencing) Y/N េធ្វើ្រ-ប់-មSក្យ (Words) Y/N
េរៀនពី|រម្មណ៏ (Emotions) Y/N េធ្វើ្រ-ប់-ម‹y (Phrases) Y/N
េរៀនពីសំេលងជុំវិញខ្លួន (Env’t sounds) Y/N Play
psល់ពីjgក់bសេ្រbsះ (Community helpers) Y/N Toys as designed Y/N
េរៀនពីសព្វ9ម- his/her/mine/yours Y/N |ចេលង}នេ្រចើនសកម្មjព aមួយtoy (Multi Y/N
(Pronouns) actions w toy)
េរៀនពី កម្មសិទ្ធ របស់នរr១ - ‘s (Possession) Y/N េចះសំែដងaមួយ toy (Pretends with toys) Y/N
េរៀនពីេភទ (Gender) Y/N េចះេដើរតួaមួយ toy (Pretends – role play) Y/N
េរៀនពីអ្វីែដលខ្វះ (What’s missing?) Y/N េចះេលងេហ្គមេលើ!q (Board games) Y/N
េចះេឆ្លើយ Yes/no-ម!រពិត (Yes/no factual ) Y/N េចះេលងេហ្គមaមួយមិត្ត(Peer games) Y/N
‹yVន ៣Sក្យ -I love u(3-word phrases) Y/N េរៀនបេញ្ចញសូ (Vocalizes) Y/N
េចះេ្របើSក្យ ខ្ញុំយល់េហើយ (I see/ I have) Y/N ដឹងពី េវន (Turn taking) Y/N

Page 4 of 11
 Initial Student Assessment – Intermediate – Cont’d Page 2

Date: Student: DOB: Age:

Self-Help Skills Pre-Academic Skills

េចះផឹកទឹកេ្របើែពង (Drinks from a cup) Y/N psល់ពណ៏(Id’s colors) Y/N
េចះេ្របើ សមឬpyប្រS(Uses fork/spoon) Y/N psល់សr—ន(Id’s shapes) Y/N
េចះេ្របើ កែន្សងជូត(Uses napkin) Y/N psល់អក្សរ(Id’s letters) Y/N
េចះេ្របើបង្គន់(Toilet trained) Y/N psល់េលខ(Id’s numbers) Y/N
េចះជូតសំេ}(Blows nose) Y/N េចះZប់េ្របើវត្ថុជំនួយ ដល់១០(Rote counts to 10) Y/N
េចះដុសេធ្មញ(Brushes teeth) Y/N Counts objects 1:1 Y/N
េចះេស្លៀកេ{(Puts on pants) Y/N Gives # from pile Y/N
េចះSក់|វ(Puts on shirt) Y/N ផ្គូផ្គងអក្សរ(Matches letters) Y/N
េចះSក់|វេ្រ™(Puts on coat) Y/N ផ្គូផ្គងSក្យ(Matches words) Y/N
េចះSក់ែស្បកេជើង(Puts on shoes) Y/N េរៀបអក្សរ-មលំLប់(Sequences #/letters) Y/N
េចះSក់េpGមេជើង(Puts on socks) Y/N psល់jពដូចនិងjពខុសfg(Same/different) Y/N
េចះសំ|តៃដ(Washes hands) Y/N psល់េ្រចើននិងតិច(More/less) Y/N
េចះšំ|ƒេផ្សងៗ(Eats variety of food) Y/N psល់្របតិទិន(Calendar) Y/N
េចះយក|ƒេnតុក(Brings meal to table) Y/N |ច្រ}ប់េV៉ង(Tells time) Y/N
េចះសំ|តេ្រ!យšំរួច(Cleans up after meal) Y/N |ចេធ្វើកិច្ច!េLយឯកZជ(Indep worksheets) Y/N
Gross Motor |ចគូ-ម(Copies drawings) Y/N
េចះជិះកង់ឬស្កី(Rides bike/trike) Y/N |ចសេស-ម(Copies #/letters) Y/N
េចះកប់ឬ•ប់}ល់(Throw and catch ball) Y/N psល់េFGះ(Identifies name) Y/N
េចះេ}ះ}ល់ចូលក្រន្តក(Shoot ball in hoop) Y/N េចះគូគំនូ(Drawing) Y/N
េចះxត់}ល់(Kick ball) Y/N េចះសេសរេFGះ(Writes name) Y/N
េចះេžតេnមុខ(Hop forward) Y/N េចះេ្របើជ័រ|វស្អិត(Pastes/glue) Y/N
|ចេžក}នកន្លះែម៉្រត(Hop on 2 feet) Y/N េចះ!ត់េ្របើកៃ្រន្ត(Cuts with scissors) Y/N
េចះឈរេជើង១(Balance on 1 foot) Y/N psល់ពណ៏ េ្រចើន(Colors) Y/N
េចះេដើរ ក្នុងសួន(Walk backwards) Y/N េចះតំេរៀប -មពណ៏ (Patterning) Y/N
េចះេដើ េលើផ្លូវ(Walk sideways) Y/N
េចះ ~(Crawl ) Y/N

Reinforcement (circle all that apply and write specifics):

1. Food
2. Drink
3. TV
4. Youtube
5. Tablet apps
6. Video games

Page 5 of 11
7. Physical touch
8. Toys
9. Social Praise

Page 6 of 11
 Initial Student Assessment – Advanced

Date: Student: DOB: Age:

Attending Expressive Language and Intraverbals

សំឡឹងមុខចំ(Eye contact) Y/N VI phrases Y/N
េចះរង់•ំ(Waits ) Y/N យល់លំLប់ទំហំ -small/smaller/smallest(Advanced Y/N
concepts)
េចះ្រគប់្រគង|រម្មណ៏េពល`yស់ប្តូ (Transitions) Y/N េចះេឆ្លើយសំនួរ -ម្របេQគែដលសួ(Wh-qu re: Y/N
sentence)
េចះយកចិត្តទុកLក់(Joint Attention) Y/N េចះេឆ្លើយសំនួរ-មរូបែដលបbcញក្នុងរូប(Wh re: Y/N
picture)
េមើល-មចំនុចអ្នកចង្អុល(Follows a Point) Y/N េចះេឆ្លើយសំនួរក្នុង្រប€នបទ (Wh re: topic) Y/N
េមើល-មែខ្សែផ្នករបស់អ្នក(Follows Eye Gaze) Y/N េចះxយរបស់(Guesses items) Y/N
Requesting េចះពណ៍9 ពីរបស់(Describes items) Y/N
េចះត~៉ែដលសម្រសប(Approp protests) Y/N េចះេរៀប-មលំLប់(Seriation) Y/N
Others to perform action Y/N េចះេរៀបលំLប់Sequencing Y/N
សំឡឹងេមើល េពលអ្នកនិQយŽ Look (For attn: Y/N psល់មុន និងេ្រ!យ(Before/after) Y/N
“Look”)
េចះសួរŽ េeទីr?(Requests “where”) Y/N េចះ្រ}ប់ពីរេបៀប (Tells how ) Y/N
េចះសួរŽ នរr?(Requests “who”) Y/N យល់និងេឆ្លើយេeសំនួរ េហតុអ្វី(Why questions) Y/N
េចះសួរŽ អ្វី?(Requests “what”) Y/N យល់និងេឆ្លើយេeសំនួរ នរr(When questions) Y/N
េចះសួរŽ មួយr?(Requests “which”) Y/N េរៀបZប់្រពឹត្តិ!រណេឡើងវិញ(Recalls events) Y/N
េចះសួរŽ េeេពលr?(Requests “when”) Y/N េរៀបZប់្រពឹត្តិ!រណ៏អ9គត(Future events) Y/N
េចះសួរŽ រេបៀបr?(Requests “how”) Y/N េចះxយទុកមុន(Predicting) Y/N
េចះសួរŽ េតើ|ច?(Requests “can/do”) Y/N េចះសន្និL£ន(Inferencing ) Y/N
េចះសួរŽ េហតុអ្វី?Requests “why” Y/N សម្ថjពpqប់!រែណ9ំ( Auditory processing) Y/N
េចះេស្នើរសុំaមួយ គុណ9ម(Requests with adj) Y/N េហ្គមេ្របើអ្នកេផ្សងេធ្វើ-មខ្លួន(Barrier games) Y/N
េចះេស្នើរសុំaមួយ €gក់ចង- by, down, from, in, Y/N េចះ្រ}ប់មូលេហតុ ដូចfgនិងខុសfg(Tells why Y/N
into, near, of, off, on, to, toward, under, upon, same/diff)
with and within. (Request with prep)
េចះេស្នើរសុំaមួយ សព្វ9ម(Request w pronoun) Y/N Class – name some Y/N
Social
សុំជំនួយពីមិត្ត(Request from peer) Y/N
្រ-ប់-មមិត្ត(Imitate peer) Y/N
េធ្វើ-ម!រែណ9ំរបស់មិត្ត(Follow peer instruct) Y/N
េចះp‡គមន៏(Greetings) Y/N
េចះចូលរួមសន្ទ9(Statement/statement ) Y/N

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េចះទស្សន៏xយវត្ថុ(Guess what) Y/N Play
េចះសួរេចះេឆ្លើយ(Statement/question) Y/N េចះេធ្វtើ oy (Toys as designed) Y/N
េចះបេញ្ចញេQបល់(Comments) Y/N េចះេលង}នេ្រចើនសកម្មjពaមួយtoyែត១(Multi Y/N
actions w toy)
េចះព្រងី!រសន្ទ9(Extends convers) Y/N េចះសំែដងaមួយ Toy(Pretends with toys) Y/N
េចះនិQយេលើ្រប€នបទមិនប្តូ(Stays on topic) Y/N េចះេដើរតួ (Pretends – role play) Y/N
េចះេរីស្រប€នបទ(Approp topics) Y/N េចះេលងវីេដអូេហ្គម(Plays video games) Y/N
េចះសួរ េតើអ្នកចូលចិត្ត(Do you like) Y/N េចះេលង!qេហ្គម (Board games) Y/N
េចះសួរ េតើអ្វីaចំនួលចិត្ត(What’s favorite) Y/N េចះេលងេហ្គមVនៃដគូ(Peer games) Y/N
េចះអត់ធ្មត់េពល•ញ់(Tolerates losing) Y/N
េចះនិQយSក្យេពលេលងេហ្គម(Vocalizes during Y/N
play)

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 Initial Student Assessment – Advanced – Cont’d Page 2

Date: Student: DOB: Age:

Self-Help Skills Pre-Academic Skills

េចះេល្លៀកSក់ខ្លួនឯង(Dresses independ) Y/N េចះេរៀបអក្សរ-មលំLប់(Sequences #/letters) Y/N
}នបង្វឹក!រេ្របើបង្គន(
់ Toilet trained) Y/N េចះផ្គផ
ូ ្កងSក្យ(Matches words) Y/N
េចះ្រគប់្រគងអក្បកិរិQ(BM trained) Y/N េចះបេញ្ចញសំេលងព្យញ្ជនៈ(Phonics sounds) Y/N
}នបង្វឹក!រេគង(Sleep trained) Y/N េចះបេញ្ចញសំេលងព្យញ្ញនៈ aមួយរូប(Decodes Y/N
phonetics )
េចះžងៃដ(Washes hands) Y/N psល់Sក្យេពញនិយម(Sight words) Y/N
េចះញីសំេ}(Blows nose) Y/N |ច|ន្របេQគ(Read sentences Y/N
េចះដុសេធ្មញ(Brushes teeth) Y/N Vន!រយល់ដឹង(Comprehends) Y/N
េចះšំ|ƒែប្លកៗ(Eats variety of food) Y/N Counts objects 1:1 Y/N
េចះយក|ƒេnតុ(Brings meal to table) Y/N Gives # from pile Y/N
េចះសំ|តេពលšំរួច(Cleans up after meal) Y/N េចះបូកេលខ(Addition) Y/N
េចះដកេលខ(Subtraction) Y/N
េចះធំaងឬតូចaង(More/less) Y/N
psល់្របតិទិន(Calendar) Y/N
េចះេធ្វើកិច្ចpžេLយfGន្រគ¦(Indep worksheets) Y/N
េចះចម្លងគំនូរ(Copies drawings) Y/N
េចះចម្លងអក្សរ(Copies #/letters) Y/N
េចះសរេសេFGះ(Prints name) Y/N
េចះេដើេលងកំpន្ត(Journal) Y/N
េចះគូគំនូ(Drawing) Y/N
េចះេ្របើជ័រស្អិតឬ!វស្អិត(Pastes/glue) Y/N
េចះ!ត់aមួយកៃ្រន្ត(Cuts with scissors) Y/N
េចះ`ត់ពណ៏(Colors) Y/N

Classroom Goals:
1. Does the child go to school (If so, when? How often? Public or private?)េតើកូនអ្នកេ)*+ែដរេទ? េបើេ)េពល3?

*+រដ្ឋ ឬឯកជន?

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2. Does the child have an aide/paraprofessional/educational assistant/shadow? (Hired privately or by the school?)

3. IEP in place?

4. Strengths at school?

5. Difficulties at school?

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References:

Maurice, C., Green, G., Luce, S. (1996). Behavioral Intervention for Young Children with Autism: A Manual for
Parents and Professionals. Austin, TX: Pro-Ed.

Partington, J. (2008). Assessment of Basic Language and Learning Skills – Revised (The ABLLS-R). Pleasant Hill,
CA: Behavior Analysts, Inc.

Rogers, S.J. and Dawson, G. (2009). Play and Engagement in Early Autism: The Early Start Denver Model.
Volume I: The Treatment. New York: Guilford Press.

Sundberg, M. (2008). Verbal Behavior Milestones Assessment and Placement Program (VB-MAPP). Concord,
CA: AVB Press.

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