Module 1 DSM-5 Checklist | ID: _____________________ Date: ____________________ Age: ___________________ Examiner: ☐ Parent/Caregiver ☐ Therapist

ecklist for Module 1

Language Level: A1. Overall Level of Nonechoed Spoken Language: _________
BOSA Version: MV
A. Impairment in Social Communication & Social Interaction B. Restricted and Repetitive Behaviors
ADOS Recode BOSA Parent Other ADOS Recode BOSA Parent Other
1. Deficits in Social-Emotional Reciprocity 1. Repetitive and Stereotyped Behavior
Score Rule Score Report Info Score Rule Score Report Info
0-1→0 0→0
*A2. Frequency of Spontaneous Vocalization Directed to Others *A3. Intonation of Vocalizations or Verbalizations
2-3→1 1-2→1
0→0 0→0
*B5. Shared Enjoyment in Interaction A4. Immediate Echolalia
1-3→1 1-3→1
0→0 0→0
B7. Requesting *A5. Stereotyped/Idiosyncratic Use of Words or Phrases
1-3→1 1-3→1
0-1→0 0→0
vB8. Giving *D2. Hand and Finger and Other Complex Mannerisms
2→1 1-3→1
0-1→0 0→0
*B9. Showing D3. Self injurious behavior
2→1 1-2→1
0-1→0
v*B10. Spontaneous Initiation of Joint Attention Other (Specify):_______________
2→1
0→0
(B11 from M2). Amount of Reciprocal Social Communication 2. Excessive Adherence to Routines and Ritualistic Behavior
1-3→1
0-1→0 0→0
*B12. Quality of Social Overtures (D5 from M3). Compulsions/Rituals
2-3→1 1-2→1
0-1→0
B13a or B13b. Amount of Social Overtures/Maintenance of Attention Other (Specify):_______________
2-3→1
0-1→0
B14. Quality of Social Response 3. Restricted, Fixated Interests
2-3→1
0-1→0
Other (Specify):_______________ *D4. Unusually Repetitive Interests or Stereotyped Behaviors
2-3→1
2. Deficits in Nonverbal Communication used for Social Interaction Other (Specify):_______________
0→0
A6. Use of Another's Body 4. Hypo- or Hyper-reactivity to sensory input or unusual sensory interest
1-2→1
0→0 0→0
*B1. Unusual Eye Contact *D1. Unusual Sensory Interest in Play Material/Person
2→1 1-3→1
0-1→0
*B3. Facial Expressions Directed to Others Other (Specify):_______________
2→1
0-1→0
*B4. Integration of Gaze and Other Behaviors During Social Overtures Other Behaviors (E Codes)
2-3→1
ADOS Recode BOSA Parent Other
Other (Specify):_______________
Score Rule Score Report Info
0→0
3. Deficits in relationships E1. Overactivity
1-3→1
0-1→0 0→0
B15. Level of Engagement E2. Tantrums, Aggression, Negative or Disruptive Behavior
2-3→1 1-3→1
0-1→0 0→0
C1. Functional Play With Objects E3. Anxiety
2-3→1 1-2→1
0-1→0 Note: ADOS Score: 0-3 from protocol; BOSA Score: 0 or 1 (absence vs. presence); ADOS ratings of 7, 8, and 9
C2. Imagination/Creativity
2-3→1 should be converted to N/A for the BOSA Score; Parent report: P if symptom reported in parent interview;
Other Info: P if symptom present based on additional gathered or observed information.
Other (Specify):_______________
*Indicates ADOS-2 algorithm items; vConsider an 8 code if not sufficient evidence to code 0-3
Clinical Notes on Observations or Outside Information:
Select codes from ADOS-2 reprinted by author C. Lord, for authorized use within the work now known as BOSA, under written permission from WPS. No
additional use, including and not limited to adaptation or translation, is permitted. ADOS-2, BOSCC and BOSA are copyrighted by WPS. All rights reserved
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(rights@wpspublish.com).