Vineland-3 | Vineland Adaptive Behaviof Seales™—Third Edition Domain-Level t/Caregiver Form PEARSO prof ts punieation may be reprauced or wansmeain any rm oc ony @PsychCor iding photocopy, recording, or any information storage ‘and retrieval system, without the express written perssion af the copyHight owner For inquities and reordering: Pearson, PSI design, PsychCorp, and Vineland are trademarks, n the US andor other soo.ee7.7271 countries, of Pearson Edueation, Inc. or its affate(), ‘worm: [Link] [NCS Pearson, Inc. 5601 Green Valley Drive Bloomington, MN 55437 Printed in the United Stater of America 56789101112 BCDECOMMUNICATION 8, He/she does not have to say the words perfectly. 49, He/she does not have to say the names perfectly. 10, 11, Ifhe/she sometimes does it without reminders but sometimes needs reminders, score 1. 16. The story might be from a fairy tale, a book, ora movie. 17, Ifhe/she sometimes dor needs reminders, score 1. 19, Irs OK if he/she writes some letters backwards. 22, Examples of informational talks are school and community Aectures, educational TV shows and videos, religious sermons, and meetings. 23. His/her sentences do not have to be perfect. 24, Ifhe/she does not write alphabet letters, score 0. 25, Tfhe/she sometimes does it without reminders but sometimes needs reminders, score 1. 26, He/she may make small spelling errors. 30. Examples of informational talks are school and community fectures, educational TV shows and videos, religious sermons, and meetings. 32. If he/she sometimes docs it without reminders but sometimes anceds reminders, score 1. 35. The instructions must be accurate. 136. Ifhe/she sometimes does it without help but sometimes needs help, score 1. 37. Ifhe/she sometimes does it without reminders but sometimes needs reminders, score 1. 38,40. If he/she sometimes does ie without help but sometimes needs help, score 1. -without reminders but sometimes DAILY LIVING 1. Score 2 if he/she does not have accidents during the day. Score Tif he/she has some accidents during the day. Score 0 ifhe/ she has many accidents during the day. 4, Ifhe/she sometimes does it without help or reminders but sometimes needs help or reminders, score 1. 5. [he/she sometimes does it without reminders but sometimes needs reminders, score 1. 6. Ifhe/she sometimes does it without help but sometimes needs help, score 1 7. Ifhe/she has to be ceminded, or does not know about being burned, score 0. 8. fhe/she sometimes does it without help or reminders but sometimes needs help or reminders, score 1. 49. Ifhe/she sometimes does it without reminders but sometimes needs reminders, score 1. 10. Score 2iFhe/she does not have accidents during the day or at night. Score 1 ifhe/she has some accidents during the day or at night. Score 0ifhe/she has many accidents during the day or atnight. 2 Vineland-3 Domoin-Lvel Parentage Farm 11. Tfhe/she sometimes does all ofthe steps without help but sometimes needs help, seore 1. 12,13, Ifhe/she sometimes does it without help but sometime: rnceds help, score 1. 14, Ifhe/she has to be reminded, or never uses sharp objects, score 0. 15. Neighborhood streets count. If he/she does not cross street: roads on his/her own, orf he/she has tbe ceminded aloo both ways, score 0. 16. Ifhe/she sometimes does it without help or reminders but sometimes needs help or reminders, score 1. 19. Score based on how often he/she does this when needed: “usually (2), sometimes (1), or never (0). Doing itwith help ddoes not count. Ifhe/she is never expected to make food, score 0. 20, Ifhe/she sometimes does it without help bue sometimes net help, score 1, 22. Ifhe/she sometimes docs it without being reminded or told but sometimes needs to be reminded or told, score 1. 23, IFhe/she sometimes docs it without help or reminders but sometimes needs help or reminders, score 1. 24, Ifhe/she sometimes does it without help but sometimes net help, score 1. 25,27. Ufhe/she sometimes docs it without reminders but sometimes needs reminders, score 1. 28, If he/she sometimes does it without help but sometimes nes help, seore 1. 29. Ihe/she sometimes docs it without reminders but sometin needs remindess, score 1. 30. Score based on how often he/she does this when needed: usually (2), sometimes (1), or never (0). If he/she needs hel orhas to be reminded, itdoes not count. [fhe/she is never expected to use household products, score 0, 31. Score based on how often he/she does this then needed: "usually @), sometimes (1), or never (0) If he/she needs hey ‘or has to be reminded, it does not count. Ifhe/she is never expected to wash dishes, core 0. 32. If he/she has o be reminded, it does not count: Ifhe/she is expected to do this on his/her own, score 0. 33. If he/she sometimes does it without help but sometimes ne help, score 1. 37. Score based on how often he/she does this when needed: usually 2), sometimes (1), or never (0). Doing it with help does not count. If he/she is never expected to cook, score 0. 38. Score based on how often he/she does this when needed: usually (2), sometimes (), or never (0). If he/she needs he} ‘of has tobe reminded, it does not count: If he/she is never ‘expected to clean a bathroom, score 0. 39. If he/she sometimes does it without help but sometimes ne help, score 1al Name ofthe Person You Are Describing, Ta ie, TheFerson You Ae Dscibingisa: CI Female. Clale Pesos Ages YourName:____. DIRECTIONS ‘This form asks about the adaptive behaviors of the ———_——-____ Persons Birth Date: ‘Your Relationship tothe Person: [] Mother CJ Father [J other _ Today's Date: or adult on whom you are reporting. Adaptive behaviors are the day-to-day things that people do to communicate, take care of themselves, and get along with others Here is a sample item from the section called Daily Living: Response Options: sua ote, 1 = Someties, = Heer 4: Wipes or cleans hes fice and ise hands when tating something meso. Read each item and choose the score that best describes what the person does on bis/ber own, without needing belp orreminders SCORING Score each item 2, 1, 0° 0 as follows: 2 Usually or Often, Cele 2 if the person usualy or often performs the behavior without help or reminders. (Or if he/she has outgrown the behavior—see below) 1 = Sometimes. Circle 1 if the person sometimes performs the behavior without help or reminders. (0 =Never. Circle 0 ifthe person never performs the behavior, or never performs it without help or reminders. Some reasons why you might give a score of O ae: + The person has not learned the behavior. + The person is not physically able ro perform the behavior. * The person is not expected or allowed to perform tthe behavior, +The person can perform the behavior, but chooses not to If you are not sure how often the person performs a behavior, make your best guess. In addition to circling the item score, also check the box to the right of the item score in the column labeled Check if Est. (Est stands for Estimated.) Ifthe person performed a behavior when he/she was younger, but has now outgrown it, score 2. Do not check the Estimated box. Some items include a Scoring Tip, shown in gray underneath the item text, and marked by the symbol [2. Use the tips to help you score those items. For example, some items have a Scoring Tip that tells you to use a different way of scoring: 2= Yes, 0-= No. The pull-off pages labeled Scoring Criteria have more information about scoring some of the items. WHICH ITEMS TO ANSWER ‘The person who gave you this form may have crossed out one ‘or more sections. Just skip any crossed-out sections, You must complete all of the sections that are not crossed out, and you ‘must answer every item in those sections. Remember, if you are not sure about an answer, make your best guess and check the Estimated box. 3‘COMMUNICATION Response Optns: 2=luaje te, 1S. 0= ee °F 1 Kno yore tan os fom tng: Empl "Te eMart "os flwes? a 2. Uses nn sonences, Esampes*Mom and Dad are here "Twantce ream and cake” Bed 3. Follows“if-then” directions. Examples: “Tf you're thirsty, then geta drink"; “Ifyou ate cold, then get a sweatshirt” “210L 4. Anowers question hat use when, Example Youask"When do you eat breakin” Hele ys "In the morning” aac fle So trices tute eae pores ie cata ama © 6 Anowers questions that te oy, Example: You ask Why re you eying? Hee aye"My ty broke” aac 7. Maka lenet thre more advanced geste nich thee) Mosoningcome bre withthe hands (2) PtingeHagerover yy E Tipste mean Be quer) Holi had part show bg) Shragaing shoulders to mean dns 8. Unesadiectves to desribe things. Examples: "Prey pita Big doggie” t 9, Says both his/her First ame and ast name when you ask, aig C 10, Flow distin o dhe same thing to wo diferent objets, Examglen"Bring me the rayon andthe bal? nal “Paton yor thirtandyoor soe, 11. Follows direction od two things that donot go together. Example“Turn ofthe FV and get my keys” 710 12, Usesall pronouns (words that refer to himself7herselfand others) correctly. Examples: , sb, us, them, our our, tein 2100 13, Uses oar enter ined by andor ut Esa She ase ne, andl her na Jerome wanted oo, tae bart did 14. Knows how to say that something happened in the past. Examples: “I wea/ked to the store,” “Molly Baked a cake.” 210L 15. Knows eft and right on isthe body. Tol 16, Tels the asc paresofawelPknown star: The characters, what happens ow tends te. aol 17 Follows three-step directions, Example, “Get dred at eas, nd brash your exch” Zoe a a a a | 19, Copies his/her own first name without mistakes. 2100 20. Follows directions involving eftand righ Examples “Go the “Look tothe sight? ana 21. Say somethingin a deen wayifaceded help someone understand what hee mean, Zine 7. Pays tention 04 15-ninutenformainal lk and understands wha is being sad TO 23, Wricessimple sentences of three or more words. 2100 2, Wt siphabe eters comet ot bacovards or upside down, riot 25, When told to do something a litle later, remembers o doit. Example:"When your show is over, put yourdishesin thesink.” 2 1 9 [ 26, Waites at least 10 words from memory. Examples: HAT, BALL, THE. 1 Score or Yes or OFor No. a of 27. Understands wha people relly mean when dey te being sara Example: Knows when "Thajunt great rellymesns yg Thats fal! t 28, Reads simple sentences of tee or more words out oud. riot 2, Understand alphabetical order. Examples: Findsa name in an address bookar list ofphone mimbers finds wording a dictionary. 4 Vineland-3 Darin-erel orentCaregier Forows how to say more than one of something Examples: “Tio cats “More cece “Thon lowers 2. Uresandin sentences. Examples:“Mom and Dad archer," “I wantice cam and cak.” 2. Fallows*if-then® directions. Examples: “If youre thirty, then get drink" "Ifyou are cold then got asweatehir.” 4. Answers questions that we wen. Example: You ask" When do you eat breakfast?” He/she sya “Tn che morning” 5, Pays attention roa story for atleast 15 minutes. 1 Score. ifhe/she id tis when younger but has now outgrow listening to stores. 6. Answers questions that use why. Example: You ask“Why are you crying?" He/she says “My toy broke.” 7. Makes at least chree more advanced gestures such as ches: (1) Motioning come bere with the hand, (2) Pus lips ro mean be guer, 8) Holding hands apart to show this bg, (2) Shrugging shoulders to mean I dont now. a finger over 8. Uses adjectives to describe things. Examples: “Pretty piture;” "Big doggie.” 9 Says both his/her first name and lastname when you ak 10, Follows directions to do the same thing co two dfferear objects. Examples: “Bring me the crayons and the ball” “Puvon your shirt and your shoes.” 11, Follows directions ta do two things that do not go together. Example: “Turn off the TV and get my keys. 12, Usesall pronouns (words that cefee to himself/herself and others) correctly. Examples she, mu, sem, yeu, our, thir 13, Uses two-part sentences joined by andor but. Examples: *She asked me, and I told her no”; "Jerome wanted t go, bout I didn.” 14, Knows how to say thar something happened in the past, Example: "I aldo the sore,"*Molly bated sake” 15. Knows lft and right on his/her body 16. Tels the basic pares of welFAown sory: The characters, what happens, how tends 17, Follows three-step directions. Example:"Get dressed, et break, and bras your teeth.” 18. Tele abouthis/her everyday events in deal. Example: When you sskwhat happened ata fiend’s house today. 19. Copies his/her own first name without mistakes. Score 2 he/she di this when younger buthas now outgrown it 20, Follows direct wolving lef and right. Examples: “Got thee. “Look to the right.” 21, Says something in diferene way if needed help someone understand what he/she means. 22, Pays attention toa 15-minote informational alland understands what being sad 23, Wits simple sentences of three or more words 24, Weites alphabet letters correctly, not backwards or upside down, 25. When told to do something a itl lace, remembers to doit. Example: “When your show is over, put yous dishes in the sink.” 26. Writes a least 10 words from memory. Examples: HAT, BALL, THE. Score 2 for Yes or for No. 27, Understands what people reslly mean when they are being sarcastic, Example: Knows when “Thats just great!” really means “That'sawful” 128, Reads simple sentences of three or more words outloud. 29, Understands alphabetical order. Examples: Finds 2 name in an address book or list of phone numbers, finds aword in Vineland-3 Domol-tere! Parent Coregiver Form Oo goggqgqjandonognoaqoajoond|a bool o) o}oNei Response Options: 2 UsuallyorOfen, 1=Sometnes, 0= Never i 37. Checks and corrects his/her written work before handingit in. Example: Checks spelling using computer. & 30, Pays tention to «30-minute informational talk and understands whats being ai Meo 3H. Sayhis/her complete homeaddzescorety when you ask. Mustincudecicyand state. ao 532. When tld odo something much ter tha day, remembers o doit. Example: “When you get home from chook, to let the dog out” 38, Reads at asecond- grade level origher Score 2forYesorOforNo 200 5. Gives complex direction with rae or more sep. Examples “Go to theend ofthis tree, ten ight, and go alfa Block SSslyou se the reerstory white building “Fi! cook te nodes, then tos them in pan with the sauce, andchenpurthe 21 0 [1] runbe on op and bake fo 10 ute 35, Wetes or draws instructions for others Examples: How t do somethings how to get somenhere. 2100 36, Uses the ltrnet or brary find information for writing paper o completing sjobassignment 2100 a Qo o ao ri9 11 Score2ifhe/she ci this when younger but naw dees not nee to handin written work 38, Fills out paper or electronic forms of one page oF less. Example: Forms for schaol ar work. 210 39, Reads ara sixth-grade level or higher. a; 1 Score 2for Yes oF Ofor Na 440, Weites papers that are at least three pages long. Must use his/her own words and not copy. ano ished this when younger, but now does not need to Ww o TI [Link] Est +40 x 100 = se | COM Raw scare Vinelond-3 Doran Lvel ParntCacegiverForm 5jail ‘ Response Options: 2 = Usvallyor Often, 1 = Sometimes, 7. Unes the toilet daring the day. May need help but must know when he/she needs ogo. 2. Counts a east 10 objects, one by one 3, Understands that money is used to buy things. Does nor have to actually use money himself/herself 4. Wipes or cleans his/her face and his/hes hands when eating something messy. ‘5. Stays near you in public places, Being carried, pushed in astrole, ete. does not © Score 2 ifhe/she die the whan younger but has now outgrown 6, Puts on pullover clothing, Fxamplex: Tshirt, sweatshirt, res. 7 As careful aroud things that could buen him/her. Examples Stove oven firs. 8, Pos clothing on with the right skde forward and correct side ou 9. Understands car punsenger safety rules and follows them, Examples: Keeps his/her seatbelt on, doesnot distract che diver. 10, Uses the toilet dung the day and at night withouthelp. Mus wipe, lush, and wash hands by himsliTersl 11 Brushes his/her eth, Must put toothpaste on worhbrush, brush welland rinse. 12. Buvions large buttons inthe correct hoes, Example: Coat buttons 13, Turns faucets on and adjusts the water temperature. 14 Iecarefel when using sharp object, Examples: Knives sessors. 15, Looks both ways when crossing sree or rons 16. Wipes up his/her own spills 1. Knows which foods ae heathy and unbeahy. 18. Knows what todo in dangerous situations. Examples: When vo get hep, when to cll 911, ow getaway from danger. 19, Makes simple sack or meal. Examples: Sandwich, cheese ad crackers, microwave fod 20, Calls others using phone, computer or other electronic deviee 21, Finds a date on calendar when you as. Examples: Today's at, his/her birthday. 22, Acts safely when working and/or having fun, Examples: Wears safety equipment, is careful when operating tools and machinery. 23, Puts his/her clean clothes away where they belong, Examples In drawers or closet on hooks. 24. Usesat east two simple kitchen appliances, Examples: Toasts, microwave, electri can opener 25, Washes Frits and vegetables before eating oreooking them 26. Chooses to extsive for health or enjoyment. 21 Plane for changes in weatherby taking along an umbrella, sweater, ete 28. Uses technology for atleast two kinds of tasks. Examples: Writing school papers or business documents, email for school or ‘work, onganizing information, finding information on the Internet. 28. Keeps money, phone, etc. secure when away from home. Examples: When shopping, eating out, traveling, 30, Uses household products correctly. Examples: aaundry detergent, furniture polish, glass cleaner. 31, Washes dishes. May wash by hand or use the dishwasher, 432. Secures the home when he/she leaves. Examples: Locks doors loses windows, turns on alarm. Viseland-3 Domai-Leve! arentCaregiver form BoOoogooooO oO obooooooooOooooogo0 ojojojo\o ooWTAE TET EXD Response Options: 2=Usvallyor Often, 1 = Sometimes, 0 =Never “ Yi Cow tack ce od wit csp ah. Engen Mes ae pra Bao 34, Considers quality and price when deciding what buy. 2100 icscssic i eek Sport Tes eal oodles rep ates Bao 36, Setsagoal hata donein sx monts orimreand achieve, Prmples Wosksandsaesmoneytobuysomething 9 g Cy expensive, get in beter pliysial shape 37, Uses the stove or oven for cooking or baking. Must cura on and offby himself/herself. 2100 "38, Cleans bathroom: Toile, sink, cuborshower ete. ; - «a Cl 29, Takes his/her own temperature when needed ao 2200 (0. Hervey tit iy. sap Bayi yal wore i bing ob ae & Score 2 ores 0 for, 0 CU [Link] Est +40 1002 wes | DLSRaw Score Vineland-3 Domaie-evl arent/oreverform 7Re SE neon lias Response Options: 2 =Uualy orden, 1. Soho family mene reread him/her Exaile *Tha ny mon Hebb” reo 2: Rees when thera happy sus surieds fal, pst — fen 5, Uses words expe his/her eins. Example" hppa se oni in tied WGsmsmrcdwne 200 5 th ens vor sow tn ie lay real temo cmeaoa OG ag bls and te"Areyoe OH? ) of isc ceee ana e GTN zreg 7 Shae hinhertyrorotherthingr when ele le ia 6. Changs easily om oe nevi anacer Exampe: Changs rm line buh ine withogectngumee. 210 EL 9. Makes good eye contact when he/she interacts with people. 2100 10, Would ter pay with ter children ha wth hem or payaloe reo Bon neeumpatcuiamsea i ti ce ne 12 Tier ke ene with ters ier ae: Enample: Ak fora play dees psomewherewih anther dld “9 ED) 13, Apologizes after hurting someone's feelings, and means it. 2100 14 Tal with he right Ioulness speed, and level of xcitement forthe conversation 210 O 15. Copiesa child plying nearby, even though they are not playing rogether, sample: Sees another hdl tacking Hock and then bgine osc blocks. 2100 Score 2ithelthe déthis when younger but has ow outarownit 16. Takes turns without having tobe asked while playing games or sports 2100 17, Uses words or gestures when he/she i upset instead of screaming, hitting, throwing something, es. 2100) 18, Iswilling to compromise vo get along with others his/her age 2100) 19. Docs things try to please others. Examples: Makes someone a card or gift helps without being asked. 2100) 20, Moves easily from one topic to another in conversation when needed. Does not “get stuck” on one topic. 2100) 21, Shows good sportsmanship in games or sports: Plays fui not too aggresive, congratulates winning player, isnot mesa a oO. when he/she loses te {i 22. Follows time limits given by a parent, grandparent, etc. Examples: How long he/she is allowed to watch TY, play a the Internet, play outside 2100 re 2ifhe/she di this when younger, buthas now outgrown 23. Is eautious when someone who he/she doesn't know well tres to get hitn/her to do something risky. May be in perton o through the Internet. 2100 juess scare, Also check the Estimated box, —... Tae SU alates nee Alay ogo ciealg ag olka Deo 26, Rese when someone area omhing rained order flow wbarkehci mying 7 27. Says oaofa group when theylet him/her koow wit worth helt no wecome. Bangle Igoringhimvber. 2) t 24, Py with ote aboard carota tha ed destnendsl sapl Momo pokes Seale) yy p two-person video games. 8 Vineland 3 omain-eel arert/Caregiver FormReon Ue ee nee na ual or ten, 1 = Sometimes, “ Response Options: 2 29, Contras his/her anger or huc feelings when he/she does nor gethis/her way. Example: Does notcry orget mad whennot 9 yg allowed to do something that he/she wants to. '30, Respects other people's rime. Examples: Not keeping others waiting, no cerrupting others who are busy. 31. Keeps others from controli cor taking advantage of him /he 432, Docs things tat his/her friends want todo, even when he/she would rather do something else © Ifyou donot know, quess a score. Also check the Estimated box, 2100 SB Thins hugh consequences fies ation fr doing igs 5 ol] 34, Understands thata friendly acting person may actually want co take advantage of him/her. a olm] 435. Lats you know about his/her plans when he/she goes out. Example: Tellsyou or leaves you a message about where he/sheis _going and when he/she will be home. 2100 By sete th hen yong sho non ni 56, Unde harsome hing cnepedin lverising might on be. neo 7 Pika pina cneraton, ample: Kno ta somenn vo yw ny Se bred, tt pape may hag the subject beeause they do noc want to talk about something, that looking atthe time may mean that he person needs tend = 2 10 CI iheconeraton 28, Pw aed on i/herow do hing whois ier og Example: Panto goto dincrwiha codon Tard, 9 9 Ty plans gotethe meri ageupenheweckend SF, Geshe information or ove pr even carro Eranics Locks as epeproro Tae, phones a movie theater. 2100 76. Gone pees with the isa age rng the day wioniomeme spevog EaangloxAshoppingmals pp y 9 C] ‘nm cote MO acre| econ too-| __|me] soctmsan Vinsloné-2 Domointeve PrenvCaregherFormResponse Options: = Usually o Often, “1. Unwraps small objects, Examples: piece of ea orgum. 2. Walks down stars, one foot on each step. May use railing, 3. Jbs.a set of eight or more stairs at anormal pace, May use railing 44. Runs smoothly, changing his/her speed and direction, Examples: Playing tag or sports, chasing a pe, 5. Jumps forward a leas three times with both feet without filling, 6. Holds « crayon, pen, or pencil propery for writing ar drawing. Does not hold wich his/her fist. 7. Walks two or more blocks without needing rest or help. 8, Dravrs circle hy hand while looking at an example. 9, Pedals a tricyele or other vehicle with three wheels for at least 6 fect 1 score he/she did this when younger, but as now outgrown 10. Catches a beach ball-sized ball from ar leas 6 feer away. May catch with two hands or one. |, Hops forward on one foot wrth ease without holding on. 12. Colors simple shapes or animals. Must color more inside the lines than outside. 1 Score he/she this when younger. but has now outgrown colons. 1. Rides abalance bike or bicycle with taining wheels for a east 10 feet. 1 Score if he/she. this when younger, but has now outgrown 14, Draws more than one form that you can recognize. Examples: Person, house, tree. 2 15. Pours liquid from one container to another with ittle or no spilling. Example: Pouring milk ox juice into a glass. A 16. Catches a tennis orbaseball-sized ball from 2 or 3 fet away. May catch with two hands or ane, but must catch away from ve body instead of trapping the ball against che body. 17, Cuts our simple shapes. Examples: Circles, squares, rectangles. 118, Makes complex creations using building toys, atembly sete arts and crafts materials, et 19, Draws a straight line using a ruler, 20. Catches stennis- or baseball-size ball from at least 10 feet away, moving to catch i if needed. May eatch with cwo hands 21, Ties knot. 22, Cutsout complex shapes. Examples: Stars, animals, alphabet lsters. 23, Works with very small objects, Examples: Setting hands on a watch, threading a sewing needle, gluing tiny model parts. 24, Rides a regular bieycle without training wheels without falling. 25. Ties secure how. Examples: Shoe laces, gift wrapping. TET, [Link] st +25 x 100 = ve est | MOT Raw Scr) inelnd-2 Donn Lee Pareo Caregiver Form‘The final section asks about problem behaviors that the person may or may not show. The score choices for each item are slightly different: 2 Often, 1 Sometimes, 0 = Never ‘In the sections you have completed so far, ahigher score means more adaptive behavior. In this section a higher score means more problem behavior, aE aa Section A Response Options: 2= Often, 1=Someties, O-=Herer 1 Teoveryaccdy or dependent: Example Tonos on help even when e/the doce ot need clings to parearorvecker. 210 2, Has eating problems. Examples: Overeas, refuses to eat, will only eat one or two things, hoards food. 2100 3. Has slp problems. Examples Walks in she see, has alto nightmares, ep may more oles than others ae hiather age 4. Refuses goto choo or work orasto come home, becuse of worrying, sadness, nervous 2100 5, Toextrmelyennlous oF nervous. 2100 6 Cres rissa for no ceareaton. 2100 7. Avoid ineracting with others withdraws prefer oe stone te) 2100 Lacks interetindaig things that hie enjoy or wed to enjoy. 2100 4. Teexremel aril one or more common objets o stations. Examples: Heights saakes elevator, ao 10, Worries for no clear reason. 2100 11, Lover or moo 2100 12. Feels helpless or hopeless. Example: Says that things are bad and will never get better. 2100 1B. Complain offetng ick, exhausted orn pain even though hee is no medical reson 2100 Pe Section Asem Section B Response Options: 2= Chen, 1 =Jometine, O=Newer es 7eo 2, Disobeys those in authority, 2100 3. Bullies her physical rw 2100 4. Tien hea or te 2100 5, Taphysically aggressive. Examples: Hits, kicks, bites. 2100 6. Isstubbom or argues 2100 7. Isverbally abusive: Hurts others on purpose with insults, put-downs, etc. 2100 8. Breaks rules or laws because of peer pressure. 2100 3, fo mach more active or restless than others ho/herage. Examples: Movesal he ie, cnet siti, ages Ao 10, Takes ors school or wock property when nat llowed. Examples: Books, office supplis. moo 11, Dewsysit/her own or someone lc’ postions on parpoe eae eke OO eet Section 85 WVineland-3 Domat-LevePoenvCaregerform 11ee Section C Response Options: 2= Often, 1 =Sometines, 1, Gets iaated on objects or parts of objects, Examples: Staes a spinning whecls or fan blades, ine up objects, flip ight svitches overand over 2, Talks about hearing voices hat others do not hea, oF seing things that others do not se. 3. Harms himseli7herelf, Examples: Bangs his/her head, hits or bites self, cus sel, tears at in, pls out his/her hale 4. Uses strange or repetitive speech Examples: Has conversations wi sense, sepeats the same thing over and over, hhimself/herseifin publi, says things that make no 5. Repeats physical movements over and over. Fxamples: Rocks back and fort, spins, flaps hands, 6. Eats non-food items such at paste, oF soap. 7, Getsso fixated on a particular topic that it annoys ethers. Examples: Trains, reptiles, maps, subway systems. 8, Talks about killing mnsclf/herself or has tried wo kill self. 9, Wanders, darts away, or takes off from home, school, or someone watching him/her without regard for safety 10, Threatens ro hurt ork AL, Is tricked by othe doing something that could seriously harm him or her, orsomeone else. GENERAL COMMENTS, Use this space for any general comments you want to make about the person, or about this form. 12 Vineland-3 Domain-evel Poen/CrgiverFormio Domain-Level Parent/Caregiver Form Vineland-3 : ae Score Report Year Month = Day Braminee’s Name: TestDate | Examiner's Name: Birth Date | Parent/Caregiver's Name: Test Age | Score Summa: ae eS Raw Standard 35% 50% 95 Percentile Score Score Confidence interval. Rak ES Deity Living Sills (ois) Socialization 600) | Sum of Domain standard Scores Se Table C3 convert to ABC Adsptive Behavior Composite asc) hw Sale Score__“Score otic ems (Gli item scores of 201 2 2 1 2 Internatizing fy 4, 10, e 1 1 1 1 (Section A) 2 a 1 2 5. a 1, - 1 1 1 1 Externalizing 2 a 7 (Section B) AMO Me Ste Son et se ee BE ge ate sew com a pis You sew sew ] sew Caleatonet Mean Domain Standard Score Tad seer Me Copyright © 2026 NCS Pearson Inc. lights reserved | Sel) For ingiries and reordering: 800.627.7271. ww'[Link] @PsychCorp 3456789101112 BCDE Product Number 31327This page intentionally left blank. 14 Vneland-2 Damen ee Poem Carepiver FrmSOCIAL SKILLS AND RELATIONSHIPS 5. Ifhe/she sometimes does it without being told but sometimes hhas to be told, score 1. 6. Playing near other childzen, but not playing with them, does not count. 13. If he/she sometimes does it without being told but sometimes needs to be told, score 1. 19, Ifhe/she sometimes does it without being told but sometimes hhas tobe told, score 1. 20. Ifhe/she docs not have conversations that lst at least 2013 minutes, score 0. 24. lfhe/she sometimes does these things without being told but i sometimes has to be told core L. eS 22. Ifhe/she sometimes does it without reminders but sometimes anceds reminders, score 1. 24, Must play with the others to count. 28. Games that he/she needs help to play do not count. 35. If he/she sometimes does it without being asked but sometimes has tobe asked, score 1. 37. Ifhe/she docs not have conversations that last atleast 2or 3 minutes, score 0. 40. If someone older has to urge hirn/her to doit, it does not count. PHYSICAL ACTIVITY 1. Ifhe/she sometimes does it without help but sometimes needs help, score 1. 8. ‘The drawing does not have to be perfect, bur must look like circle. 14, Tracing does not count. 21. Ifhe/she sometimes does it without help but sometimes needs help, seore 1. 24, He/she must get on the bicycle and start pedaling without help. 25. If he/she sometimes does it without help but sometimes needs help, score 1. PROBLEM BEHAVIORS SECTION A 2, Ifthe only problem is that he/she will not eat afew specific foods like spinach or broccoli score 0. 4. I?he/she does not attend school or have ajob, score 0 SECTION B 10. If he/she does not go to school or work, score 0. 2 section | 2. Childhood imaginary friends do not count. Vineland—3 Domain- Level Parent/CregiverFarm 6