Developmental Learning Center

Self-Care Data Sheet – Brushing Teeth

I = Independent
G = Gestural Prompt
P = Physical Prompt

Date Date Date Date Date Date Date Date Date Date

Staff Staff Staff Staff Staff Staff Staff Staff Staff Staff
STEPS:
Gets toothbrush
Turns on water
Picks up toothpaste
Puts toothpaste on
toothbrush
Brings toothbrush to front
teeth
Clenches teeth and
brushes left side
Brushes bottom of teeth
Clenches teeth and
brushes right side
Brushes bottom of teeth
Fills cup with water
Sips water and spits into
sink
Rinses brush
Puts supplies away
Wipes mouth
Teacher/Therapist Name: Mike Dow

Program: Follow Directions

Direction : Student will follow 5 different 1- step directions in the home environment.
Student Response: Student will follow direction independently.
Date

Comments:

Program: Personal Information

Direction: Student will answer 3 personal information questions (i.e. name, address, phone, etc.)
Student Response: Student will independently give answer to question verbally or with assistance from device/visual cues.
Date

Comments:

Program: Requesting
Direction : Student will make 3 independent requests in the home environment.
Student Response: Gains attention independently and states needed item.

Date

Comments:
Teacher/Therapist Name: Mike Dow

Program: Picture Identification (Picture Book)

Direction : When presented with a book with pictures will identify a minimum of 5 objects that are presented.
Student Response: Student will correctly identify the target object verbally or by pointing.
Date

Comments:

Program: Social Skills

Direction : Student will use 3 appropriate social cues with an adult (i.e. “Hello”, “Thank You”, “Goodbye”)
Student Response: Does independently in appropriate situations.
Date

Comments:
 Developmental Learning Center
Self-Care Data Sheet – Brushing Teeth

I = Independent
G = Gestural Prompt
P = Physical Prompt

Date Date Date Date Date Date Date Date Date Date

Staff Staff Staff Staff Staff Staff Staff Staff Staff Staff
STEPS:
Gets toothbrush
Turns on water
Picks up toothpaste
Puts toothpaste on
toothbrush
Brings toothbrush to front
teeth
Clenches teeth and
brushes left side
Brushes bottom of teeth
Clenches teeth and
brushes right side
Brushes bottom of teeth
Fills cup with water
Sips water and spits into
sink
Rinses brush
Puts supplies away
Wipes mouth
 Developmental Learning Center
Warren

Vocational Education
TASK ANALYSIS – DATA FORM

Student: IEP Goal:

Class: Objective:
Target Objective: Making Bed

Modifications:

I = Independent G = Gestural Prompt V= Verbal Prompt

P = Physical Prompt ND = Not Done
Date Date Date Date Date Date Date Date Date Date

Staff Staff Staff Staff Staff Staff Staff Staff Staff Staff

STEPS
1. Retrieve bottom fitted
sheet
2. Place fitted sheet on
bed
3. Tuck side 1 under
mattress
4. Tuck side 2 under
mattress
5. Tuck side 3 under
mattress
6. Tuck side 4 under
mattress
7. Retrieve top sheet,
place on bed
8. Straighten/smooth top
sheet
9.Retrieve comforter,
place on bed
10. Straighten/smooth
comforter
11. Retrieve pillow and
pillowcase
12.Put pillowcase on
pillow
13. Place pillow on bed

Note: This data is not graphed. Once this sheet is complete, file it in the binder.
 Developmental Learning Center
Warren

Vocational Education
TASK ANALYSIS – DATA FORM

Note: This data is not graphed. Once this sheet is complete, file it in the binder.