Expanded Interview Form Report - Outreach and Engagement

1 Expanded Interview form ReportExaminee InformationName: SAMPLE, TESTID Number: 000111 Birth Date: 11/08/1997 Age: 10:11 Sex: MaleRace/Ethnicity: WhiteCurrent Grade: 5 School/Facility:Site:Intelligence Test ResultsForm:Test Date:Standard Score:Test InformationForm: Expanded InterviewInterview Date: 11/05/2008 Examiner Name: SCHOOL PSYCHOLOGISTA,PHDE xaminer ID:Respondent: Sample Mother, TestRelationship to Individual: MotherPresent Classification/Diagnosis:Reason for Assessment:Service placement evaluationOther Information:The vineland -II adaptive behavior Scales assess personal and social sufficiency of individuals from birth through adulthood based on thereport of the individual's parent or caregiver.

2 Results contained herein are confidential, and should only be viewed by those with properauthorization. This computer-generated Report should not be the sole basis for making important decisions related to diagnosis, treatment,or qualification for program and narrative text are based on normative data from the vineland adaptive behavior Scales, Second Edition ( vineland -II). Report printed for: PEARSON ASSESSMENTSPage 1 of9 Report Date: 04/14/2009 Report generated by vineland -II ASSIST version 2008 NCS Pearson, Inc. All rights Interview form ReportSAMPLE, TESTID#: 000111 Age: 10:11 Test Date: 11/05/2008 Score SummarySubdomain / CI%ileRankAdapt.

3 LevelAge 2 Low1 2 Low1 1 Low5 = 6**24 5< 1 Low1 1 Low3 1 Low3 Living SkillsSum = 8**30 4< 2 Low0 and Leisure Time395 1 Low1 Skills276 1 Low2 = 12**38 5< Motor Skills (Est)71 Fine Motor Skills (Est)65 Motor SkillsAdapt. Behav. = 92*26 3<1 Low1 InternalizingExternalizingOtherMaladapti ve behavior IndexRaw Score45211v-Scale19181890% CI 2 1 1 LevelElevatedElevatedElevated* Represents sum of domain standard scores** Represents sum of subdomain v- scale scores** Caution is required in interpreting this age equivalentReport printed for: PEARSON ASSESSMENTSPage 2 of9 Report Date: 04/14/2009 Report generated by vineland -II ASSIST version 2008 NCS Pearson, Inc.

4 All rights , TESTID#: 000111 Age: 10:11 Test Date: 11/05/2008 vineland -II Pairwise ComparisonsDomain ComparisonsDomain ComparisonsStandard ScoreDifferenceSignificanceLevelFrequenc y ofDifferenceCommunication < Daily Living Skills6 Communication < Living Skills < Motor SkillsNSSocialization Motor SkillsNSDaily Living Skills Motor SkillsNSWithin-Domain Subdomain ComparisonsSubdomain Comparisonsv- scale ScoreDifferenceSignificanceLevelFrequenc y ofDifferenceCommunicationReceptive = Expressive0 Receptive < Written3 Expressive < *16%Daily Living SkillsPersonal < *16%Personal <

5 Community2 Domestic > Community1 SocializationInterpersonal Relationships < Play and Leisure *5%Interpersonal Relationships < Coping *1%Play and Leisure Time < Coping Skills1 Motor SkillsGross Motor Skills Fine Motor SkillsNS NS = Not Scored * = Bonferroni-adjusted level for multiple comparisonsReport printed for: PEARSON ASSESSMENTSPage 3 of9 Report Date: 04/14/2009 Report generated by vineland -II ASSIST version 2008 NCS Pearson, Inc. All rights , TESTID#: 000111 Age: 10:11 Test Date: 11/05/2008 Score ProfileReport printed for: PEARSON ASSESSMENTSPage 4 of9 Report Date: 04/14/2009 Report generated by vineland -II ASSIST version 2008 NCS Pearson, Inc.

6 All rights , TESTID#: 000111 Age: 10:11 Test Date: 11/05/2008 Narrative ReportThe vineland adaptive behavior Scales, Second Edition ( vineland -II) measures the personal and social skillsof individuals from birth through adulthood. Because adaptive behavior refers to an individual's typicalperformance of the day-to-day activities required for personal and social sufficiency, these scales assess what aperson actually does, rather than what he or she is able to do. The vineland -II assesses adaptive behavior infour domains: Communication, Daily Living Skills, Socialization, and Motor Skills.

7 It also provides acomposite score that summarizes the individual's performance across all four SAMPLE was age 10:11 on the Interview date of November 5, 2008. The respondent was his Mother,Test Sample Mother. Test was administered the vineland -II Expanded Interview form by SCHOOLPSYCHOLOGISTA, 's adaptive behavior Composite standard score of 26 summarizes his overall level of adaptivefunctioning. The 90 percent confidence level shows that TEST's true adaptive behavior Composite is likely tobe within the range of 23 to 29 (confidence interval of +/-3).

8 TEST's adaptive behavior Composite classifieshis general adaptive functioning as low; he scores higher than only less than 1% of similarly aged individuals inthe vineland -II norm 's level of adaptive functioning within the Communication domain is low for his age group. His standardscore of 24 results in a confidence interval of +/-5 (20 to 29) at the 90 percent confidence level. His percentilerank is less than 1. Thus, his score in this area is higher than or equal to only less than 1 percent of his peers inthe normative sample. He had an adaptive level of low for all three subdomains (Receptive, Expressive, andWritten).

9 TEST's age equivalents for the Communication subdomains are 1:1 for the Receptive subdomain, 1:9for the Expressive subdomain, and 5:3 for the Written of the Communication subdomain v-scores can provide insight into an individual's relativeabilities. In TEST's case, significant differences were found between the v-scores of the following pairs ofCommunication subdomains: Expressive and Written, with his Written being significantly greater at the .05level and the difference occurring only 16% of the time in the general-population norm sample.

10 Relative to theother Communication subdomains, TEST's Written skills represent a 's standard score for the Daily Living Skills domain is 30 which results in a confidence interval of +/-4 (26to 34) at the 90 percent confidence level. This score represents a low level of adaptive functioning in this areafor an individual of his age. His percentile rank for the Daily Living Skills domain is less than 1. He had anadaptive level of low for all three subdomains (Personal, Domestic, and Community). TEST's age equivalentsfor the Daily Living Skills subdomains are 1:11 for the Personal subdomain, 3:5 for the Domestic subdomain,and 3:4 for the Community of the Daily Living Skills subdomain v-scores reveal that in TEST's case, significant differenceswere found between the v-scores of the following pairs of Daily Living Skills subdomains: Personal andDomestic, with his Domestic being significantly greater at the.