Revised 1.25.21

*NOTE TO STAFF: Be sure to customize the directions for the staff/ participant to follow so they know how to complete this data sheet

Name:
Goal/Objective:

WEEK ENDING:  	

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Where did This Communication exchange occur? (Home (H), Community (C), Volunteer (V))

H C V

H C V

H C V

H C V

H C V

H C V

H C V

H C V

H C V

H C V

H C V

H C V

H C V

H C V

H C V

H C V

H C V

H C V

H C V

H C V

H C V

H C V

H C V

H C V

H C V

H C V

H C V

H C V

H C V

H C V

H C V

H C V

H C V

H C V

H C V

Was Cheat card used?

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Type of Prompts used/ number of times used (Gestural (G), Verbal (V) Modeling (M) )

G
/

V
/

M
/

G
/

V
/

M
/

G
/

V
/

M
/

G
/

V
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M
/

G
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V
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M
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G
/

V
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M
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G
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V
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M
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G
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V
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M
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G
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V
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M
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G
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V
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M
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G
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V
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M
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G
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V
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M
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G
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V
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M
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G
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V
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M
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G
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V
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M
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G
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V
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M
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G
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V
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M
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G
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V
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M
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G
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V
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M
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G
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V
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M
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G
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V
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M
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G
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V
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M
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G
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V
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M
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G
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M
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G
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V
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M
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G
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M
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G
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M
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G
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M
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G
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M
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G
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M
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G
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M
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G
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M
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G
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G
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M
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G
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V
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M
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Number of Exchanges

Notes: