FOR EXAMINER USE ONLY Score Report

Parent/Primary Caregiver Form

Ages 0-5

Child Information
Name of child being evaluated (first, middle, last) Sex Grade

Jamie Sample Male

Age at testing Date of birth Age

2 years 7 months 09/26/2016 3 years 4 months

School City State

Race/Ethnicity

Black/African American
Disability or other limitation Client ID

None

Parent/Caregiver Information
Parent/Caregiver's name (first, last) Occupation

Julie Sample Nurse

Relationship to child Number of siblings at home

Parent 3 or more
Describe relationship

Record of Input Data

Adaptive skill area Raw score Number of skipped items Number of guessed items
Communication 32 0 0
Community Use 32 0 0
Functional Pre-Academics 45 0 0
Home Living 34 0 0
Health and Safety 21 0 0
Leisure 21 0 0
Self-Care 14 0 0
Self-Direction 12 0 0
Social 16 0 0
Motor 43 0 0

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 Score Summary

Year Month Day

Testing date 2019 4 29

Date of birth 2016 9 26

Age 2 7 3

Raw Score to Scaled Score Conversions

Adaptive skill area Raw score Scaled score Test-Age Equivalent

Communication 32 2 2 1:2-1:3

Community Use 32 11 11 2:6-2:8

Functional Pre-Academics 45 17 17 3:6-3:8

Home Living 34 7 7 1:10-1:11

Health and Safety 21 3 3 1:2-1:3

Leisure 21 1 1 0:09

Self-Care 14 1 1 0:07

Self-Direction 12 1 1 0:09

Social 16 1 1 0:07

Motor 43 3 1:0-1:1
Sum of scaled scores 47 20 2 22

Note: Motor is included in the GAC but not adaptive domains

GAC Conceptual Social Practical

Sum of Scaled Scores to General Adaptive Composite (GAC) and Adaptive Domain Score Conversions

Sum of scaled scores Standard score Percentile rank Confidence interval: 95%

General Adaptive Composite (GAC) 47 70 2 67 - 73

Conceptual 20 79 8 74 - 84
Social 2 51 0.1 45 - 57
Practical 22 75 5 70 - 80

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 Score Profile

Percentage of cases 2.2 6.7 16.1 50 16.1 6.7 2.2

Standard scores 70 80 90 100 110 120

Extremely Below Above

Qualitative descriptions Low Average High
low average average

Adaptive skill area

scaled scores
Score ranges <=3 4-5 6-7 8 - 12 13 - 14 >= 15
Scale Name 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
Graph

Communication X
Conceptual

Functional Pre-
X
Academics
Self-Direction X

Leisure X
Social

Social X

Community Use X
Practical

Home Living X

Health and Safety X

Self-Care X

Motor X
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

GAC and adaptive domain

standard scores

Below Above
Extremely low Low Average High
average average

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 Optional Analyses
Adaptive Domain Comparisons
Significance Base rate in
Domain comparison Standard score 1 Standard score 2 Difference standardization sample
Critical value .05 level
Conceptual-Social 79 51 28 7.78 Y <=5%

Conceptual-Practical 79 75 4 6.57 N

Social-Practical 51 75 -24 7.20 Y <=5%

Scatter in Adaptive Skill Area Scaled Scores

Comparison used: Adaptive domains
Highest skill area Lowest skill area
Difference Significance Base rate in
between standardization
Scaled Scaled Critical
GAC/Domain Name score Name score
scaled scores value .05 level
sample

GAC: All skill areas

Functional Pre-
Conceptual skill areas 17 Self-Direction 1 16 2.56 Y <=5%
Academics
Social skill areas Leisure 1 Social 1 0 2.82 N

Practical skill areas Community Use 11 Self-Care 1 10 2.88 Y <=5%

Strengths and Weaknesses in Adaptive Skill Areas

Comparison used: Adaptive domains
Calculate the mean scaled scores for adaptive skill areas

GAC Adaptive domain

7 skill areas Conceptual Practical
10 skill areas Conceptual Social Practical
< age 1* < age 1* < age 1*
Sum of scaled scores 20 2 22

Number of skill areas divide by 10 divide by 7 divide by 3 divide by 2 divide by 2 divide by 4 divide by 2

Mean scaled score 6.67 1 5.5

Determine strengths and weaknesses in adaptive skill areas

Skill area Mean scaled score Difference Significance Base rate in

Skill area scaled score from above from mean Critical value .05 level standardization sample

Communication 2 6.67 -4.67 2.20 Y <=5%

Conceptual

Functional Pre-
Academics
17 6.67 10.33 1.66 Y <=5%

Self-Direction 1 6.67 -5.67 2.12 Y <=5%

Leisure 1 1 0 2.04 N
Social

Social 1 1 0 2.12 N
Community Use 11 5.5 5.5 1.66 Y <=5%
Practical

Home Living 7 5.5 1.5 1.56 N

Health and Safety 3 5.5 -2.5 2.12 Y <=15%
Self-Care 1 5.5 -4.5 2.12 Y <=5%
Motor

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 FOR EXAMINER USE ONLY Score Report
Teacher Form
Ages 5-21

Student Information
Name of student being evaluated (first, middle, last) Sex Grade

Anna Sample Female 7th

Age at testing Date of birth Age

13 years 3 months 01/09/2002 18 years

School City State

Race/Ethnicity Employment status

No job
Disability or other limitation Client ID

None

Teacher Information
Teacher's name (first, last) Subjects you teach

Jane Doe
Number of years as a teacher How long have you been this student's teacher?

Relationship to student

General education teacher

Describe relationship

Record of Input Data

Adaptive skill area Raw score Number of skipped items Number of guessed items
Communication 34 0 0
Community Use 35 0 0
Functional Academics 32 0 0
School Living 28 0 0
Health and Safety 25 0 0
Leisure 34 0 0
Self-Care 34 0 0
Self-Direction 32 0 0
Social 29 0 0
Work

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 Score Summary

Year Month Day

Testing date 2015 4 29

Date of birth 2002 1 9

Age 13 3 20

Raw Score to Scaled Score Conversions

Adaptive skill area Raw score Scaled score Test-Age Equivalent

Communication 34 2 2 <5:0

Community Use 35 8 8 ±

Functional Academics 32 2 2 ±

School Living 28 1 1 <5:0

Health and Safety 25 1 1 <5:0

Leisure 34 6 6 <5:0

Self-Care 34 1 1 <5:0

Self-Direction 32 3 3 <5:0

Social 29 1 1 <5:0

(Work)

Sum of scaled scores 25 7 7 11

Note: Work is not included in the GAC or adaptive domains

GAC Conceptual Social Practical

Sum of Scaled Scores to General Adaptive Composite (GAC) and Adaptive Domain Score Conversions

Sum of scaled scores Standard score Percentile rank Confidence interval: 95%

General Adaptive Composite (GAC) 25 57 0.2 54 - 60

Conceptual 7 56 0.2 51 - 61
Social 7 68 2 63 - 73
Practical 11 59 0.3 54 - 64

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Page 2 of 9
 Score Profile

Percentage of cases 2.2 6.7 16.1 50 16.1 6.7 2.2

Standard scores 70 80 90 100 110 120

Extremely Below Above

Qualitative descriptions Low Average High
low average average

Adaptive skill area

scaled scores
Score ranges <=3 4-5 6-7 8 - 12 13 - 14 >= 15
Scale Name 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
Graph

Communication X
Conceptual

Functional
X
Academics
Self-Direction X

Leisure X
Social

Social X

Community Use X

School Living X
Practical

Health and Safety X

Self-Care X

Work
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

GAC and adaptive domain

standard scores

Below Above
Extremely low Low Average High
average average

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 Optional Analyses
Adaptive Domain Comparisons
Significance Base rate in
Domain comparison Standard score 1 Standard score 2 Difference standardization sample
Critical value .05 level
Conceptual-Social 56 68 -12 7.20 Y <=15%

Conceptual-Practical 56 59 -3 7.20 N

Social-Practical 68 59 9 7.20 Y >15%

Scatter in Adaptive Skill Area Scaled Scores

Comparison used: Adaptive domains
Highest skill area Lowest skill area
Difference Significance Base rate in
between standardization
Scaled Scaled Critical
GAC/Domain Name score Name score
scaled scores value .05 level
sample

GAC: All skill areas

Conceptual skill areas Self-Direction 3 Communication 2 1 2.04 N

Social skill areas Leisure 6 Social 1 5 2.04 Y <=5%

Practical skill areas Community Use 8 School Living 1 7 2.63 Y <=15%

Strengths and Weaknesses in Adaptive Skill Areas

Comparison used: Adaptive domains
Calculate the mean scaled scores for adaptive skill areas

GAC Adaptive domain

9 skill areas Conceptual Social Practical

Sum of scaled scores 7 7 11

Number of skill areas divide by 9 divide by 3 divide by 2 divide by 4

Mean scaled score 2.33 3.5 2.75

Determine strengths and weaknesses in adaptive skill areas

Skill area Mean scaled score Difference Significance Base rate in

Skill area scaled score from above from mean Critical value .05 level standardization sample

Communication 2 2.33 -0.33 2.12 N

Conceptual

Functional
Academics
2 2.33 -0.33 2.12 N

Self-Direction 3 2.33 0.67 1.95 N

Leisure 6 3.5 2.5 2.04 Y <=5%
Social

Social 1 3.5 -2.5 1.95 Y <=5%

Community Use 8 2.75 5.25 2.82 Y <=5%
Practical

School Living 1 2.75 -1.75 2.28 N

Health and Safety 1 2.75 -1.75 2.49 N
Self-Care 1 2.75 -1.75 2.49 N

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 FOR EXAMINER USE ONLY Score Report
Parent Form
Ages 5-21

Child Information
Name of child being evaluated (first, middle, last) Sex Grade

Anna Sample Female

Age at testing Date of birth Age

13 years 3 months 01/09/2002 18 years

School City State

Race/Ethnicity Employment status

No job
Disability or other limitation Client ID

None

Parent Information
Parent's name (first, last) Occupation

Mum Sample Nurse

Relationship to child Number of siblings at home

Parent 3 or more
Describe relationship

Record of Input Data

Adaptive skill area Raw score Number of skipped items Number of guessed items
Communication 58 0 0
Community Use 52 0 0
Functional Academics 54 0 0
Home Living 68 0 0
Health and Safety 55 0 0
Leisure 56 0 0
Self-Care 59 0 0
Self-Direction 54 0 0
Social 56 0 0
Work

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 Score Summary

Year Month Day

Testing date 2015 4 29

Date of birth 2002 1 9

Age 13 3 20

Raw Score to Scaled Score Conversions

Adaptive skill area Raw score Scaled score Test-Age Equivalent

Communication 58 7 7 6:8-6:11

Community Use 52 11 11 15:0-15:11

Functional Academics 54 9 9 11:4-11:7

Home Living 68 12 12 ±

Health and Safety 55 11 11 ±

Leisure 56 11 11 ±

Self-Care 59 6 6 ±

Self-Direction 54 8 8 ±

Social 56 6 6 ±

(Work)

Sum of scaled scores 81 24 17 40

Note: Work is not included in the GAC or adaptive domains

GAC Conceptual Social Practical

Sum of Scaled Scores to General Adaptive Composite (GAC) and Adaptive Domain Score Conversions

Sum of scaled scores Standard score Percentile rank Confidence interval: 95%

General Adaptive Composite (GAC) 81 92 30 89 - 95

Conceptual 24 87 19 83 - 91
Social 17 92 30 88 - 96
Practical 40 97 42 93 - 101

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Page 2 of 10
 Score Profile

Percentage of cases 2.2 6.7 16.1 50 16.1 6.7 2.2

Standard scores 70 80 90 100 110 120

Extremely Below Above

Qualitative descriptions Low Average High
low average average

Adaptive skill area

scaled scores
Score ranges <=3 4-5 6-7 8 - 12 13 - 14 >= 15
Scale Name 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
Graph

Communication X
Conceptual

Functional
X
Academics
Self-Direction X

Leisure X
Social

Social X

Community Use X

Home Living X
Practical

Health and Safety X

Self-Care X

Work
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

GAC and adaptive domain

standard scores

Below Above
Extremely low Low Average High
average average

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Page 3 of 10
 Optional Analyses
Adaptive Domain Comparisons
Significance Base rate in
Domain comparison Standard score 1 Standard score 2 Difference standardization sample
Critical value .05 level
Conceptual-Social 87 92 -5 5.09 N

Conceptual-Practical 87 97 -10 5.88 Y <=15%

Social-Practical 92 97 -5 5.09 N

Scatter in Adaptive Skill Area Scaled Scores

Comparison used: Adaptive domains
Highest skill area Lowest skill area
Difference Significance Base rate in
between standardization
Scaled Scaled Critical
GAC/Domain Name score Name score
scaled scores value .05 level
sample

GAC: All skill areas

Functional
Conceptual skill areas 9 Communication 7 2 2.20 N
Academics
Social skill areas Leisure 11 Social 6 5 2.04 Y <=5%

Practical skill areas Home Living 12 Self-Care 6 6 2.20 Y <=15%

Strengths and Weaknesses in Adaptive Skill Areas

Comparison used: Adaptive domains
Calculate the mean scaled scores for adaptive skill areas

GAC Adaptive domain

9 skill areas Conceptual Social Practical

Sum of scaled scores 24 17 40

Number of skill areas divide by 9 divide by 3 divide by 2 divide by 4

Mean scaled score 8 8.5 10

Determine strengths and weaknesses in adaptive skill areas

Skill area Mean scaled score Difference Significance Base rate in

Skill area scaled score from above from mean Critical value .05 level standardization sample

Communication 7 8 -1 2.04 N
Conceptual

Functional
Academics
9 8 1 2.20 N

Self-Direction 8 8 0 1.95 N
Leisure 11 8.5 2.5 2.12 Y <=15%
Social

Social 6 8.5 -2.5 1.95 Y <=15%

Community Use 11 10 1 2.28 N
Practical

Home Living 12 10 2 2.20 N

Health and Safety 11 10 1 2.56 N
Self-Care 6 10 -4 2.35 Y <=5%

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 FOR EXAMINER USE ONLY Score Report
Adult Form (Rated by Others)
Ages 16-89

Adult Information
Name of individual being evaluated (first middle, last) Sex

John Sample Male

Age at testing Date of birth Age

70 years 04/05/1945 74 years 9 months

Years of education Occupation

Race/Ethnicity Employment status

White Retired
Disability or other limitation Client ID

None

Rater Information
Rater's name (first, last) Age Occupation

Amanda Sample 45
Relationship to individual

Child
Describe relationship

Record of Input Data

Adaptive skill area Raw score Number of skipped items Number of guessed items
Communication 44 0 0
Community Use 32 0 0
Functional Academics 56 0 0
Home Living 43 0 0
Health and Safety 42 0 0
Leisure 54 0 0
Self-Care 39 0 0
Self-Direction 54 0 0
Social 67 0 0
Work*
*The Work adaptive skill area is included in the GAC and Practical domain standard scores for individuals under 75 years old if it was administered and
no more than three items were skipped.

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Page 1 of 10
 Score Summary

Year Month Day Raw Score to Scaled Score Conversions

Testing date 2015 4 29 Adaptive skill area Raw score Scaled score
Date of birth 1945 4 5 Communication 44 2 2
Age 70 0 24
Community Use 32 1 1
*The Work adaptive skill area is included in the
GAC and Practical domain standard scores for
individuals under 75 years old if it was Functional Academics 56 6 6
administered and no more than three items were
skipped.
Home Living 43 3 3

Health and Safety 42 2 2

Leisure 54 8 8

Self-Care 39 1 1

Self-Direction 54 5 5

Social 67 8 8

Work*

Sum of scaled scores 36 13 16 7

GAC Conceptual Social Practical

Sum of Scaled Scores to General Adaptive Composite (GAC) and Adaptive Domain Score Conversions

Sum of scaled scores Standard score Percentile rank Confidence interval: 95%

General Adaptive Composite (GAC) 36 72 3 69 - 75

Conceptual 13 71 3 68 - 74
Social 16 90 25 85 - 95
Practical 7 67 1 62 - 72

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 Score Profile

Percentage of cases 2.2 6.7 16.1 50 16.1 6.7 2.2

Standard scores 70 80 90 100 110 120

Extremely Below Above

Qualitative descriptions Low Average High
low average average

Adaptive skill area

scaled scores
Score ranges <=3 4-5 6-7 8 - 12 13 - 14 >= 15
Scale Name 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
Graph

Communication X
Conceptual

Functional
X
Academics
Self-Direction X

Leisure X
Social

Social X

Community Use X

Home Living X
Practical

Health and Safety X

Self-Care X

Work
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

GAC and adaptive domain

standard scores

Below Above
Extremely low Low Average High
average average

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 Optional Analyses
Adaptive Domain Comparisons
Significance Base rate in
Domain comparison Standard score 1 Standard score 2 Difference standardization sample
Critical value .05 level
Conceptual-Social 71 90 -19 6.57 Y <=5%

Conceptual-Practical 71 67 4 6.57 N

Social-Practical 90 67 23 7.20 Y <=5%

Scatter in Adaptive Skill Area Scaled Scores

Comparison used: Adaptive domains
Highest skill area Lowest skill area
Difference Significance Base rate in
between standardization
Scaled Scaled Critical
GAC/Domain Name score Name score
scaled scores value .05 level
sample

GAC: All skill areas

Functional
Conceptual skill areas 6 Communication 2 4 1.95 Y >15%
Academics
Social skill areas Leisure 8 Social 8 0 1.76 N

Practical skill areas Home Living 3 Community Use 1 2 2.04 N

Strengths and Weaknesses in Adaptive Skill Areas

Comparison used: Adaptive domains
Calculate the mean scaled scores for adaptive skill areas

GAC Adaptive domain

9 skill areas 10 skill areas Practical Practical
Conceptual Social
without Work with Work without Work with Work

Sum of scaled scores 13 16 7

Number of skill areas divide by 9 divide by 10 divide by 3 divide by 2 divide by 4 divide by 5

Mean scaled score 4.33 8 1.75

Determine strengths and weaknesses in adaptive skill areas

Skill area Mean scaled score Difference Significance Base rate in

Skill area scaled score from above from mean Critical value .05 level standardization sample

Communication 2 4.33 -2.33 1.86 Y >15%

Conceptual

Functional
Academics
6 4.33 1.67 1.95 N

Self-Direction 5 4.33 0.67 1.76 N

Leisure 8 8 0 1.76 N
Social

Social 8 8 0 1.66 N
Community Use 1 1.75 -0.75 2.12 N
Practical

Home Living 3 1.75 1.25 2.12 N

Health and Safety 2 1.75 0.25 2.28 N
Self-Care 1 1.75 -0.75 2.28 N

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