ACIS Summary Sheet

Client: Observation Situation: Age: Adaptations: Ethnicity: White Sex: Diagnosis: Inpatient: Black Outpatient: Hispanic Asian NativeAmerican Examiner:

Competent (4):

Competent performance that supports communication/ interaction and yields good interpersonal/ group outcomes. Examiner observes no evidence of a deficit Questionable performance that places at risk communication/interaction and yields uncertain interpersonal/group outcomes. Examiner questions the presence of deficit.

Questionable (3): Ineffective (2): Deficit (1):

Physicality
Contacts Gazes Gestures Maneuvers Orients Postures 4 4 4 4 4 4

Ineffective performance that interferes with communication/ interaction and yields undesirable interpersonal/ group outcomes. Examiner observes a mild to moderate deficit. Deficit performance that impedes communication/ interaction and yields unacceptable group outcomes. Examiner observes a severe deficit (risk of damage, danger, provocation, or breakdown of interpersonal group relations).

Comments
3 3 3 3 3 3 2 2 2 2 2 2 1 1 1 1 1 1

Information Exchange Articulates Asserts Asks Engages Expresses Modulates Shares Speaks Sustains Relations
Collaborates Conforms Focuses Relates Respects 4 4 4 4 4 3 3 3 3 3 2 2 2 2 2 1 1 1 1 1

Comments 3 3 3 3 3 3 3 3 3 2 2 2 2 2 2 2 2 2 1 1 1 1 1 1 1 1 1 Comments

4 4 4 4 4 4 4 4 4

Comments: