Client:
Respondent:
INVENTORY of POTENTIAL AVERSIVE STIMULI and SETTING EVENTS (IPASS) Date:
Interviewer:
Check this box if AUDITORY stimuli (things the person hears) seem to be related to challenging behaviors
loud noises soft noises Never Y N When it starts Noises seem to "set off" (or precede) challenging behavior
crashing celebrations Past Y N When it stops Person freezes when these stimuli are present
laughing animals Now (present) - but rarely Y N When people discuss it Person seems upset when these stimuli are present
cough/sniff vehicles Now (present) - and often Y N When it lasts a long time Person uses challenging behavior after hearing these stimuli
chewing rustling Unsure The person avoids these stimuli
talking yelling The person uses unsafe behaviors related to these stimuli
Other sounds: These stimuli are often heard before challenging behavior
__________________________ If yes above, when before behavior are they heard? Mark all that apply
__________________________ seconds minutes hours days weeks
Check this box if VISUAL stimuli (things the person sees) seem to be related to challenging behaviors
bright lights darkness Never Y N When it starts Visual events seem to "set off" (or precede) challenging behavior
flickering strobe lights Past Y N When it stops Person freezes when these stimuli are present
people approaching or leaving Now (present) - but rarely Y N When people discuss it Person seems upset when these stimuli are present
seeing emotion (happy, sad, etc) Now (present) - and often Y N When it lasts a long time Person uses challenging behavior after seeing these stimuli
blood or injuries screens Unsure The person avoids these stimuli
drug paraphernalia The person uses unsafe behaviors related to these stimuli
Other, or specific examples: At least one is often present before challenging behavior
__________________________ If yes above, when before behavior are they seen? Mark all that apply
__________________________ seconds minutes hours days weeks
Check this box if ODORS (things the person SMELLS) seem to be related to challenging behaviors
alcohol chemicals Never Y N When it starts Visual events seem to "set off" (or precede) challenging behavior
feces urine Past Y N When it stops Person freezes when these stimuli are present
smoke (fire) Now (present) - but rarely Y N When people discuss it Person seems upset when these stimuli are present
smoke (cigarettes/drugs etc) Now (present) - and often Y N When it lasts a long time Person uses challenging behavior after seeing these stimuli
perfume Unsure The person avoids these stimuli
food The person uses unsafe behaviors related to these stimuli
Other, or specific examples: At least one is often present before challenging behavior
__________________________ If yes above, when before behavior do they occur? Mark all that apply
__________________________ seconds minutes hours days weeks
Give an example of a time that visual events related to challenging
behaviors for the person.
Give an example of a time that odors related to challenging behaviors for
the person.
How are these stimulus events related to challenging behavior?
(Mark all that apply)
Which odors may relate to
behavior challenges?
When were odors related to
challenging behavior? Are these aspects problematic?
How are these stimulus events related to challenging behavior?
(Mark all that apply)
Are these aspects of the sounds
problematic?
When were sounds related to
challenging behavior?
Check ANY sounds that seem to
relate to behavior challenges
Check ANY that seem to relate to
behavior challenges
When were visual stimuli related
to challenging behavior? Are these aspects problematic?
Give an example of a time that noises related to challenging behaviors for
the person.
How are these stimulus events related to challenging behavior?
(Mark all that apply)
This is a 4.15.20 DRAFT. Used to contribute trauma-informed
data on setting events to behavior assessments and plans (c) 2020 by Kolu
Client:
Respondent:
INVENTORY of POTENTIAL AVERSIVE STIMULI and SETTING EVENTS (IPASS) Date:
Interviewer:
Check this box if PLACES seem to be related to challenging behaviors
bedroom garage Never Y N When client arrives Certain places seem to "set off" challenging behavior
kitchen basement Past Y N When client leaves Person freezes in certain places
bathroom public restroom Now (present) - but rarely Y N When people discuss it Person seems upset in certain places
pool/beach outside Now (present) - and often Y N Person uses challenging behavior after visiting certain places
home school Unsure The person avoids certain places
park gym The person uses unsafe behaviors related to these places
Other, or specific examples: Person is usually somewhere specific before challenging behavior
__________________________ If yes above, when did visit occur before challenging behavior?
__________________________ seconds minutes hours days weeks
Check this box if specific observable EVENTS or activities seem to be related to challenging behaviors
meals voiding Never Y N When client starts Certain activities seem to "set off" challenging behavior
playing/leisure work/chores Past Y N When event is over Person freezes during certain activities
holidays rest/sleeping Now (present) - but rarely Y N When people discuss it Person seems upset during certain activities
screen time winning/losing Now (present) - and often Y N Person uses challenging behavior after doing certain activities
visting someone parties Unsure The person avoids certain activities
someone's death or illness The person uses unsafe behaviors related to these activities
Other, or specific examples: A specific activity usually occurs before challenging behavior
__________________________ If yes above, when did activity occur (before the challenging behavior)?
__________________________ seconds minutes hours days weeks before
Check this box if specific internal events or sensations seem to be related to challenging behaviors
sadness anger Never Y N Initially (at beginning) Certain activities seem to "set off" challenging behavior
sickness being tired Past Y N When event is over Person freezes during certain activities
cold/hot PMS Now (present) - but rarely Y N When people discuss it Person seems upset during certain activities
worry constipation Now (present) - and often Y N Person uses challenging behavior after doing certain activities
hungry on menses Unsure The person avoids certain activities
medication change The person uses unsafe behaviors related to these activities
Other, or specific examples: A specific activity usually occurs before challenging behavior
__________________________ If yes above, when did these occur (before the challenging behavior)?
__________________________ seconds minutes hours days weeks before
When it's been going on a
long time
Give an example of a time these places related to challenging behaviors
for the person.
Give an example of a time these specific events related to challenging
behaviors for the person.
Give an example of a time these internal events related to challenging
behaviors for the person.
Which events seem related to
behavior challenges?
When were these events related
to challenging behavior?
Do specific events seem
problematic…
How are these events or activities related to challenging
behavior? (Mark all that apply)
When it's been going on a
long time
Which items seem related to
behavior challenges?
When were these events related
to challenging behavior?
Do specific events seem
problematic…
How are these events or activities related to challenging
behavior? (Mark all that apply)
Which places may relate to
behavior challenges?
When were these places related
to challenging behavior?
Do specific places seem
problematic…
How are these places related to challenging behavior? (Mark all
that apply)
When client is there a long
time
This is a 4.15.20 DRAFT. Used to contribute trauma-informed
data on setting events to behavior assessments and plans (c) 2020 by Kolu