Title Page

  • Document No.

  • Audit Title

  • Client initials / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

Rules & Regulations

  • Staff member has passed all location requirements

  • Staff adheres to location dress code

  • Staff can state location rules & regulations

Collaborative/Professional Relationship

  • Talks to staff in respectful and professional manner

  • Does not interact with other children unless it applies to client or is asked to support.

  • Listens to staff both in direct and indirect (is aware of cues given) situations


  • Lets teacher/staff present Sd

  • Uses prompts that encourage responding to staff

  • Prompts used:

  • Asks staff to represent SD

  • Non-vocal prompts

  • If invasive prompts used, fades prompt

  • Provides feedback/suggestions to staff that can support setting

  • Collects data in the moment

  • Uses appropriate reinforcement for setting


  • Behaviors Reported

  • Provides simple data collection or reinforcement systems

  • Provides basic easy to implement suggestions

  • Gathers info from staff

  • Behaviors Observed

  • Collects data

  • Identifies potential function

  • Implements setting appropriate interventions

  • Record interventions used

  • Provides staff with support/suggestions

Direct Instruction

  • Uses all 3-components of DTT

  • Uses all 3-components of NET

  • Uses setting appropriate reinforcement

  • Collects data in the moment


  • We have reviewed the results of this assessment.

  • Assessor

  • Assessed Staff

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.