Characteristics of Autism: Observation Form

Child’s Name: _______________ Observer: _______________ Date: _____________

Social Behaviors (1=not very true, 5=very true)

A. Fails to initiate interactions with adults

1

2

3

4

5

B. Fails to initiate interactions with peers

 

 

 

 

 

C. Fails to respond to initiations from adults

 

 

 

 

 

D. Fails to respond to initiations from peers

 

 

 

 

 

E. Fails to use eye contact during interactions

 

 

 

 

 

Communication (1=not very true, 5=very true)

A. Fails to communicate to request

1

2

3

4

5

B. Fails to communicate to direct attention

 

 

 

 

 

C. Fails to use nonverbal gestures

 

 

 

 

 

D. Fails to use speech to communication

 

 

 

 

 

E. Shows unusual speech/language characteristics

 

 

 

 

 

Restricted Activities/Interests

A. Fails to engage in imaginative play

1

2

3

4

5

B. Engages in repetitive play activities

 

 

 

 

 

C. Engages in repetitive motor behaviors

 

 

 

 

 

D. Responds inconsistently to sounds

 

 

 

 

 

E. Shows unusual visual interests