MEISR sample form.pdf

Measure of Engagement, Independence, and Social Relationships (MEISR™)

The MEISR™ is a list of skills that infants and toddlers (birth to 3 years of age) typically display in everyday routines within the home and community. To complete the MEISR, caregivers assess a child’s level of functional participation in 14 different routines. For the purposes of the MEISR, a caregiver is defined as someone who has observed the child often in the home. The MEISR has many benefits within the context of early intervention. Prior to administration, professionals should discuss the specific purpose and benefits as they apply to each child within each routine, including items with a typical starting age beyond the child’s age.

Scores indicate a child’s level of mastery by age (relative to typical starting age for skills) and by routine (relative to all skills for that routine up to 36 months of age). Once completed, transfer scores for all routines to the MEISR Scoring Summary page. See the manual for complete administration instructions (Chapters 4 and 6).

On a scale from 1 to 3 (Not yet, Sometimes, Often or Beyond this), rate your child’s level of functioning in performing activities. Circle 1, 2, or 3 for each skill. Depending on the child’s age, some activities may be beyond your child’s capability. This is expected. The MEISR takes about 45 minutes to complete.

Child Information

Child's name: Amber Brook	Child's DOB: June 1, 2015
Child's age in months: 25 months
Caregiver(s) name and relationship to child: Lomita and Evan Brook - Amber's parents
Professional(s) name and affiliation: Viola Jackson and Ben Larsen, Little Steps

MEISR Routines

MEISR Routines (number of items in routine)	A. Total Number of 35	B1. Total Number of Items Scored for Child's Age	B2. Percentage of Items Mastered by Child's Age (A/B1 * 100 = %)	C1. Total Number of Items Scored for Routine	C2. Percentage of Items Mastered by Routine (A/C1 * 100 = %)
01. Waking Up (25)	21	23	91 %	25	84 %
02. Toileting/Diapering (20)	6	12	50 %	20	30 %
03. Meal Times (47)	24	37	65 %	47	51 %
04. Dressing Time (29)	11	21	52 %	29	38 %
05. Hangout – TV – Books (38)	16	24	67 %	38	42 %
06. Play With Others (38)	18	27	67 %	38	47 %
07. Nap Time (14)	9	11	82 %	14	64 %
08. Outside Time (26)	13	14	93 %	26	50 %
09. Play by Him- or Herself (35)	21	29	72 %	35	60 %
10. Bath Time (30)	20	25	76 %	30	63 %
11. Bedtime (16)	10	12	83 %	16	63 %
12. Going Out (35)	15	26	58 %	35	43 %
13. Grocery Shopping (18)	6	13	46 %	18	33 %
14. Transition Time (15)	5	9	56 %	15	33 %
TOTALS	145	283	69 %	386	51 %

Skill Assessment

1. Waking Up Participates in waking up time by...

Skill	Typical starting age in months	Not yet	Sometimes	Often or Beyond Time	Func	Dev	Out
1.01 Making vocal sounds	0	1	2	3	S	CM	K
1.02 Showing enjoyment when held, rocked, touched by caregiver	0	1	2	3	S	S	S
1.03 Looking at caregiver and making eye contact	0	1	2	3	S	S	S
1.04 Easily turning head to both sides	1	1	2	3	I	M	A
1.05 Acting happy to see or hear caregiver	1	1	2	3	S	S	S
1.06 Showing interest in crib toys (e.g., watching mobile)	2	1	2	3	E	CG	K
1.07 Turning over from side to tummy or side to back	2	1	2	3	I	M	A
1.08 Smiling, kicking, moving arms excitedly when sees caregiver	2	1	2	3	S	S,M	S
1.09 Reaching out for or batting at toys, repeating action with enjoyment	3	1	2	3	E	CG,M	K
1.10 Playing with hands and feet, touching and watching movements	3	1	2	3	E	CG	K
1.11 Turning toward the sound of caregiver's voice	3	1	2	3	S	S	S
1.12 Maintaining sitting at least briefly	5	1	2	3	I	M	A
1.13 Raising arms to be picked up when caregiver reaches for child	5	1	2	3	S	CM,S	S
1.14 Sitting when placed in sitting	6	1	2	3	I	M	A
1.15 Moving up and down by bending knees when supported in standing	6	1	2	3	I	M	A
1.16 Calling out for caregivers (e.g., shouting, vocalizing) whines	7	1	2	3	S	CM,S	A
1.17 Waking up without crying immediately (calming self)	8	1	2	3	E	S	S
1.18 Standing and cruising around crib	10	1	2	3	I	M	A
1.19 Saying "mama" or "dada" when sees Mama or Dada	12	1	2	3	S	CM,S	S
1.20 Standing for several seconds without support	12	1	2	3	I	M	A
1.21 Playing with toys momentarily until caregiver comes (i.e., coping)	18	1	2	3	E	S	S
1.22 Responding to caregiver's greeting with a sign or word	18	1	2	3	S	CM	S
1.23 Leaving room to find caregiver	24	1	2	3	I	S	A
1.24 Letting caregiver know how he/she is feeling (e.g., happy) by saying so or responding to a question	30	1	2	3	S	S	S
1.25 Following directions involving descriptions (e.g., get the big pillow; be quiet, fussy is still sleeping)	33	1	2	3	S	CG, CM	K

Play With Others Participates in play time with others by...

Skill	Typical starting age in months	Not yet	Sometimes	Often or Beyond this	Func	Dev	Out
6.01 Reacting to sounds (e.g., startling)	0	1	2	3	E	CG	K
6.02 Following caregiver with his or her eyes	3	1	2	3	E	S	S
6.03 Getting excited as caregiver approaches/starts playful game (e.g., squealing)	3	1	2	3	S	S	S
6.04 Wiggling or vocalizing to continue social play (e.g., bouncing) with caregiver	4	1	2	3	S	S, CG	S
6.05 Playing with others, without fussing or getting upset	6	1	2	3	S	S	S
6.06 Rolling back to tummy	6	1	2	3	I	M	A
6.07 Playing simple games with caregiver or older child (e.g., peek-a-boo)	6	1	2	3	S	CG, S	S
6.08 Imitating others (e.g., patting, banging)	6	1	2	3	S	CG	K
6.09 Showing interest in children (e.g., looking at, vocalizing, gesturing)	9	1	2	3	S	S	S
6.10 Indicating he or she understands what "no" means	9	1	2	3	S	CM, S	K
6.11 Talking or babbling back and forth in a sort of conversation with caregiver	11	1	2	3	S	CM, S	S
6.12 Attempting to climb on things (e.g., onto furniture, in boxes)	11	1	2	3	I	M	A
6.13 Repeating things (e.g., sounds, actions) when laughed at by others	11	1	2	3	S	CM, S	S
6.14 Indicating understanding of simple request with clear gestures (e.g., come here, give me)	12	1	2	3	S	CM	K
6.15 Playing a back-and-forth game (e.g., pushing ball, moving to get toy back)	12	1	2	3	S	S, CG	S
6.16 Imitating actions using toys/objects (e.g., banging a drum, stirring with a spoon)	12	1	2	3	S	CG	K
6.17 Playing apart from familiar caregiver (5 minutes or longer)	15	1	2	3	S	S	S
6.18 Playing with a variety of toys in their intended manner (e.g., scribbling on paper, stacking rings on ring stacker toy)	15	1	2	3	E	CG	K
6.19 Playing back-and-forth (early turn taking) game with another child (with caregiver assistance)	18	1	2	3	S	S	S
6.20 Playing side by side with other children, interacting with gestures	18	1	2	3	S	S, CM	S
6.21 Cleaning up toys, as part of routine, when asked (e.g., putting toy in box)	22	1	2	3	S	CM, S	S
6.22 Indicating ownership over toys or items with peers (e.g., might grab toy)	23	1	2	3	S	S	S
6.23 Singing some words in familiar songs (e.g., "Happy Birthday," "Twinkle Twinkle")	24	1	2	3	E	CM	K
6.24 Maintaining motor control over his or her body in relationship to others (e.g., walks well, moves around others)	24	1	2	3	I	M	A
6.25 Showing interest in playing with other children (e.g., going to where they are)	24	1	2	3	S	S	S

Grocery Shopping Participates in grocery shopping by...

Skill	Typical starting age in months	Not yet	Sometimes	Often or Beyond this	Func	Dev	Out
13.01 Attending to sound of caregiver's voice	0	1	2	3	S	S	S
13.02 Looking at caregiver's mouth and eyes when face to face	2	1	2	3	E	S	S
13.03 Reaching for items/toys that are given (with an open hand or open hands)	5	1	2	3	E	M	A
13.04 Responding to bye-bye by looking and might try waving	7	1	2	3	S	CM	S
13.05 Sitting independently in the cart	9	1	2	3	I	M	A
13.06 Pointing or reaching for named item (e.g., "get apple" when shown two items)	9	1	2	3	S	CM	K
13.07 Understanding rule to sit in the cart and only occasionally fussing (up to 30 minutes)	12	1	2	3	E	S	S
13.08 Indicating what he or she wants (e.g., pointing, gesturing)	12	1	2	3	S	CM	A
13.09 Imitating saying a new word (e.g., cake, banana, eggs)	14	1	2	3	S	CM	K
13.10 Carrying items while walking (e.g., small bag)	18	1	2	3	E	M	A
13.11 Recognizing and labeling grocery items (three or more)	18	1	2	3	E	CM	K
13.12 Understanding yours and mine (e.g., this is your drink and this is mine)	21	1	2	3	S	CM	K
13.13 Pushing a stroller or pretend shopping cart	24	1	2	3	I	M	A
13.14 Getting items parents have requested off shelf	30	1	2	3	S	CM	K
13.15 Showing interest in other children	30	1	2	3	S	S	S
13.16 Responding appropriately to unknown adults in the grocery store	33	1	2	3	S	S	S
13.17 Walking around things (small and large), moving, and stepping over	33	1	2	3	I	M	A
13.18 Walking alongside the cart (staying in safe proximity)	36	1	2	3	I	A	A

| A. Total items scored 3 (Often or Beyond this): 6 |
| B1. Total items scored for child's age: 13 |
| B2. Percentage of items mastered by age (A/B1 * 100): 46% |
| C1. Total items scored for full routine: 18 |
| C2. Percentage of items mastered by routine (A/C1 * 100): 33% |