Rating Behavior Scale

    Please enter name or ID
    Please enter your age
    Please enter the Medical Record Number
    Please enter today's date
    The information you provide will not be saved in a database. There will not be a record of your name, date of birth or medical record number.
    List up to five behaviors you want to see changed(put a brief description of the behavior you will rate. Ex: hits, runs away, yells)
    FREQUENCY SCORE
    How often does
    this happen?    		 0 - 1
    (Up to once
    a week)    		 2 - 4
    (Up to 4 times
    a week)     		5 - 7
    (Up to once
    a day)    		 8 - 28
    (Up to 4 times
    a day)    		 29 - 49
    (Up to 7 times
    a day)    		 50 - 70
    (Up to 10 times
    a day)    		 71 - 112
    (Up to once
    an hour)    		 113 - 224
    (Up to twice
    an hour)    		 225 - 448
    (Up to 4 times
    an hour)    		 >449
    (More than 4 times
    an hour)
    Frequency
    Score->    		 1 2 3 4 5 6 7 8 9 10


    PROBLEM SEVERITY
    Describe the first behavior
    		 Frequency Score
    Severity: 0 1 2 3 4 5 6 7 8 9 10
    Describe the second behavior
    		 Frequency Score
    Severity: 0 1 2 3 4 5 6 7 8 9 10
    Describe the third behavior
    		 Frequency Score
    Severity: 0 1 2 3 4 5 6 7 8 9 10
    Describe the fourth behavior
    		 Frequency Score
    Severity: 0 1 2 3 4 5 6 7 8 9 10
    Describe the fifth behavior
    		 Frequency Score
    Severity: 0 1 2 3 4 5 6 7 8 9 10



    OVERALL SEVERITY SCORE
    Behavior 1
    Behavior 2
    Behavior 3
    Behavior 4
    Behavior 5
    Total Severity Score
    Questions? Send them to larry.burd@med.und.edu.