REINFORCEMENT ASSESSMENT FORM

Student’s Name:______________________ Completed By:_____________________ Date:________________

Prior to beginning the pairing process, it is important to identify ALL of your student’s motivators or
reinforcers. Many students have very specific reinforcers and may engage with them in certain ways. Please
provide as much detail as possible.

Please indicate your student’s preferences below. Please provide specifics if possible (e.g., what kind, brand,
type, etc.). Cross off (X) if student hates.

What are your student’s preferences (likes and dislikes)?

Puzzles: Games:

Musical Instruments: Play Dough:

Action Figures: Notes:

Other:

Sensory Preferences: (be sure to include likes AND dislikes)

Auditory (sounds):

Visual (light, colors):

Tactile (contact, textures):

Kinesthetic (movement):

Olfactory (smells):

Gustatory (tastes):

What are your student’s entertainment preferences?

Movies: TV: Animation/Cartoons:

Music: Video Games: Board Games/Other:

List some of your student’s favorite videos/tv shows/performers:

Adapted from materials by Beautiful Minds of Princeton L.L.C.

Circle (O) if student likes. Cross off (X) if student hates. Please provide specifics, if possible (e.g., what
kind, brand, type, etc.)

What activity does your student prefer when using the computer?
CD ROM Games: Internet Sites:

List your student’s favorite CD ROM Games:

List your student’s favorite Internet Sites:

Things Tokens Favorite Subjects

Balloons Other toys: Certificates Art

Blocks Puppets Check register Math
Chalk/crayons Shiny/Sparkly Toys Grades Music
“Dress Up” Materials Slinky Honor Roll Gym/PE
Dolls/Figurines Spinning Toys Marbles/Chips Reading
Funny Glasses Stickers Money Writing
Jewelry Stopwatch Other: Spatial
Koosh Balls Stuffed Animals Points/Numbers Science
Lighted Toys Textured Balls Signatures Social Studies
Liquid Timers Toy Cars Special badges Library
Machines Trains Stars/smiley faces Foreign Language:
Marbles Wind-up Toys Tickets Other:
Noisy Cars/Vehicles Vehicles

Sports Appearance Books (bk):

Aerobics Skating Dressing Up Pop-Up

Basketball Skiing Make-up Bks w/ Sound:
Bike riding Soccer Manicures Puzzle bk
Bowling Softball/baseball Massages Picture bk
Fishing Swimming Perfume/cologne Sensory bk
Football Tennis Picture taken Sticker bk
Horseback riding Volleyball Other: Magazines
Jumping rope Walking/jogging Coloring bk
Other: Weight training Flip bk

Adapted from materials by Beautiful Minds of Princeton L.L.C.

Circle (O) if student likes. Cross off (X) if student hates. Please provide specifics, if possible (e.g., what
kind, brand, type, etc.)
Activities
Being cafeteria helper Go to office on an errand Sand play
Being excused from homework Going to the beach Staying up late
Being group leader Going to the store Science
Being principal’s helper Helping librarian Sharing information
Bicycling Helping the custodian Sharpening pencils
Blowing pinwheels Indoor walk Singing
Blowing/popping bubbles Leaving town Sitting on bouncy balls
Building models Letters Sitting/laying down
Chairing a meeting Line leader/monitor Sleeping late
Coloring Listening to a story Social studies
Cutting with scissors Listening to music Spelling
Dancing Listening to stories Taking showers/baths
Decorating (walls, room) Math Telling stories
Demonstrating a hobby to the class Molding clay Time off from school
Displaying work Numbers Unsupervised time
Drawing Other: Using tools
Drawing on chalkboard Outdoor walk Using trampoline
Earning money Painting with brush Using treadmill
Erasing chalkboards Participating in crafts Visiting library
Extra or longer recess Pasting or gluing Visiting museums
Finger painting Picnics Visiting parks
Fixing a bulletin board Playing chase/running Visiting relatives
Getting a badge to wear for day Playing games like Simon Says Watching videos
Gluing Playing with balls Water play
Going out to eat Playing with microphone Working on computers
Going to concerts/shows Reading Writing
Recess/free time Writing notes
Riding in car
Running errands

Adapted from materials by Beautiful Minds of Princeton L.L.C.

Circle (O) if student likes. Cross off (X) if student hates. Please provide specifics, if possible (e.g., what
kind, brand, type, etc.)

What are your student’s outdoor activities?

Bicycle: Swing Set: Trampoline:

Theme Parks: Swimming: Slide:

Other Notes:

What are your student’s preferences for pets?

Cats: Dogs:
Hamsters: Fish:
Gerbils:
Other Notes:

Circle (O) if student likes. Cross off (X) if student hates. Please provide specifics, if possible (e.g., what
kind, brand, type, etc.)

Getting a special certificate Group activities Silly faces

“Good note” home Having a choice of seatmate Sleepovers
“High fives” Having lunch with the teacher Smiles/gestures
Animal sounds High volume praise Songs
Being head of lunch line Hugs Spinning
Bouncing Kidding and joking Squeezes
Dancing Pats Talking on the phone
Enthusiastic praise Phone call for good behavior Talking with friends
Fast-paced tickles Playing with a friend Talking with teacher
Gentle tickles Praise Time with parent
Getting a happy face on paper Rough housing Tutoring other students
Getting positive comments on homework Scratches Whispered praise
Shoulder rubs

Adapted from materials by Beautiful Minds of Princeton L.L.C.

Circle (O) if student likes. Cross off (X) if student hates. Please provide specifics, if possible (e.g., what
kind, brand, type, etc.)

What are your student’s favorite snacks/foods?

Candy: Fruit:

Cookies: Crackers:

Chips: Pretzels:

Ice Cream:
Other:

List your student’s favorite brand names:

What are your student’s favorite beverages?

Soda: Juice: Water:

Milk:
List your student’s favorite flavors and brand names:

Other:

Having a snack M & M’s Chocolate chips

Raisinettes Skittles Sweet tarts
Tootsie rolls Candy corn Gummy bears
Lollipops Candy bars Other candies
Gum Marshmallows Cookies
Graham crackers Cake Other crackers
Cereal Pretzels Popcorn
Chips Pudding Yogurt
Bagels Pizza French fries
Onion rings Cheese Peanut butter
Raisins Grapes Apples
Bananas Other fruit Carrots
Other vegetables Ice Cream Juice
Soda Snow cones Kool Aid
Chocolate milk Other:

Adapted from materials by Beautiful Minds of Princeton L.L.C.

 Reinforcer Assessment: Paired Stimulus

Before starting assessment:

1. Stimuli should be selected based upon availability, ease of presentation, parent/staff reports, and any on
dietary and health restrictions for the student.
2. Make sure student has sampled items previously and none are unfamiliar. If a stimulus is new, allow
student access before the assessment begins.

Set-Up:

3. Before each session, place a cleared off table to use for the assessment. Have materials available to
record data from assessment.

Assessment:

4. Put two stimuli on the table in front of the child (0.7 m from one another and 0.7 m from the child) and
wait for 5 s.
5. If the child touches a stimulus, remove the non-chosen stimulus immediately.
6. Let the child interact with the chosen stimulus for 5 s. If the child samples the stimulus at the first
opportunity, move on to Step 9.
7. If the child approaches both stimuli, block him or her by holding the two stimuli down on the table.
8. If the child does not approach both stimuli after 5 s, prompt him or her to sample each stimulus for 5 s.
For an edible stimulus, put the stimulus in front of the child’s mouth. For a toy, let the child hold the
stimulus for 5 s.
9. After the child samples both stimuli, present the two stimuli again. (Note that this still constitutes the
same trial.)
10. Repeat steps 2-4.
11. If the child does not approach both stimuli, again remove the stimuli.
12. Record the data for each trial by writing the results on the score sheet provided.
In each stimulus preference assessment session, each stimulus was paired once with every other stimulus. For
example, with 7 stimuli, there are a total of 21 trials in each session.

# of stimuli 4 5 6 7 8 9 10
# of trials 6 10 15 21 28 36 45
# of times chosen / # of trials presented (total number of stimuli – 1)

Adapted from materials by Beautiful Minds of Princeton L.L.C.

 Data Sheet

Date:

Trial # Stimulus Stimulus Chosen

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
Adapted from materials by Beautiful Minds of Princeton L.L.C.
 Stimulus # chosen # present % rank

# of stimuli Possible %
4 1/3 (33, 66, 99)
5 1/4 (25, 50, 75, 100)
6 1/5 (20, 40, 60, 80, 100)
7 1/6 (16, 33, 50, 66, 83, 100)
8 1/7 (14, 28, 42, 57, 71, 85, 100)
9 1/8 (12, 25, 37, 50, 62, 75, 87, 100)

Adapted from materials by Beautiful Minds of Princeton L.L.C.