Self Regulation Data Sheet

Tier: 3 (Individual) Session Duration: 30 minutes Grade: 8th Grade

Student Name: ____________________________ Date: ____________________________ Instructor: ____________________________

Objective 1: Social Communication Language

Curriculum & Rating Scale Used: ____________________________


Rating (check one):
[ ] 1 [ ] 2 [ ] 3 [ ] 4 [ ] 5


Description of Demonstration:





Use of Moderate Cues:
[ ] Yes [ ] No

If Yes, type (check all that apply):
[ ] Verbal [ ] Gestural [ ] Modeling [ ] Other: _______


Notes:

Objective 2: Expressing Emotions When Dysregulated

Student will express emotion (verbal/nonverbal) in 3 of 5 opportunities with prompting & visual support.

Opportunity 1

Context: ____________________________

Prompt Level (check one):
[ ] Independent [ ] Visual [ ] Verbal [ ] Physical

Emotion Expressed:
[ ] Verbal [ ] Nonverbal

Visual Support Used:
[ ] Yes [ ] No

Success:
[ ] Yes [ ] No

Opportunity 2

Context: ____________________________

Prompt Level (check one):
[ ] Independent [ ] Visual [ ] Verbal [ ] Physical

Emotion Expressed:
[ ] Verbal [ ] Nonverbal

Visual Support Used:
[ ] Yes [ ] No

Success:
[ ] Yes [ ] No

Opportunity 3

Context: ____________________________

Prompt Level (check one):
[ ] Independent [ ] Visual [ ] Verbal [ ] Physical

Emotion Expressed:
[ ] Verbal [ ] Nonverbal

Visual Support Used:
[ ] Yes [ ] No

Success:
[ ] Yes [ ] No

Opportunity 4

Context: ____________________________

Prompt Level (check one):
[ ] Independent [ ] Visual [ ] Verbal [ ] Physical

Emotion Expressed:
[ ] Verbal [ ] Nonverbal

Visual Support Used:
[ ] Yes [ ] No

Success:
[ ] Yes [ ] No

Opportunity 5

Context: ____________________________

Prompt Level (check one):
[ ] Independent [ ] Visual [ ] Verbal [ ] Physical

Emotion Expressed:
[ ] Verbal [ ] Nonverbal

Visual Support Used:
[ ] Yes [ ] No

Success:
[ ] Yes [ ] No

Notes for Objective 2:

Objective 3: SDQ Score Progress

Track increase in emotional & peer problem scales (aim for ≥10% growth).

Baseline Emotional Scale: _____ Baseline Peer Scale: _____

Current Emotional Scale: _____ Current Peer Scale: _____


Percent Change:
[ ] ≥10% [ ] <10% [ ] Decrease


Notes:

Overall Session Observations & Next Steps

Instructor Signature: ____________________________ Date: ____________________________

Answer Key: Self Regulation Data Sheet

Objective 1: Social Communication Language

• Curriculum & Rating Scale Used:
– Expect a named evidence-based curriculum (e.g., Zones of Regulation, Social Thinking, Everyday Speech).
Thought: Ensures the observer knows which framework and rubric are in use.

• Rating (1–5):
1 = No understanding or demonstration
2 = Emerging understanding; needs maximal cues
3 = Solid understanding; demonstrates skill with moderate cues
4 = Generalizes skill in varied settings with minimal cues
5 = Independent mastery across contexts
Thought: Defines anchor points so raters score consistently.

• Description of Demonstration:
– Provide a specific example of target language or behavior (e.g., “Student labeled feeling ‘frustrated’ when turned away from preferred activity”).
Thought: Concrete evidence supports chosen rating.

• Use of Moderate Cues (Y/N & Type):
– Moderate cues include brief verbal hints or simple gestural prompts (e.g., “What’s your feeling?” while pointing to chart).
Thought: Tracks the level of adult support required for skill execution.

• Notes:
– Record any contextual factors (peer dynamics, sensory triggers) or atypical responses.
Thought: Qualitative details inform next instructional steps.

Objective 2: Expressing Emotions When Dysregulated

Expected outcome: Student expresses an emotion, verbally or nonverbally, in 3 out of 5 opportunities with adult prompting and visual support.

For each opportunity, the observer should record:

1. Context: Briefly describe the dysregulation trigger (e.g., academic task, peer conflict).
   Thought: Identifies antecedent to behavior.
2. Prompt Level:
   • Independent – no prompt needed
   • Visual – shows emotion chart/card
   • Verbal – gives spoken reminder (e.g., “Use your words.”)
   • Physical – hand-over-hand or full physical guidance
     Thought: Differentiates prompt intensity to track fading progress.
3. Emotion Expressed:
   • Verbal – student names feeling (“I’m angry”).
   • Nonverbal – points to corresponding picture or uses sign.
     Thought: Confirms modality of expression.
4. Visual Support Used (Y/N):
   Thought: Monitors reliance on visual aids.
5. Success (Y/N):
   – Mark Y if the student expresses an emotion within the opportunity window, regardless of prompt level.
   Thought: Aligns data with the 3/5 success criterion.

Summary:
– Count the number of Y’s. A total of ≥3 indicates the objective was met during the session.
Thought: Provides a quick check of session mastery.

Objective 3: SDQ Score Progress

• Baseline Emotional Scale Score & Baseline Peer Problem Scale Score:
– Use scores from initial SDQ assessment at IEP start.
Thought: Establishes reference point.

• Current Emotional Scale Score & Current Peer Problem Scale Score:
– Use most recent SDQ data.
Thought: Reflects growth or need for further intervention.

• Percent Change Calculation:
– Formula: ((Current – Baseline) ÷ Baseline) × 100
– Example: ((12 – 10) ÷ 10) × 100 = 20% increase
Thought: Quantifies progress toward the ≥10% target.

• Notes:
– Document relevant interventions or environmental factors that may explain score shifts.
Thought: Contextualizes data for team review.

Overall Session Observations & Next Steps

• Patterns & Trends:
– Note if prompts are decreasing, spontaneous language is increasing, or visual support reliance is changing.
Thought: Highlights instructional successes or areas needing adjustment.

• Recommendations:
– Suggest prompt fading strategies, peer-mediated supports, or adjustments to visual tools.
Thought: Guides future session planning and IEP updates.

Instructor Signature & Date: Verify completion and review key observations with multidisciplinary team.
Thought: Formalizes accountability and communication across educators.*