This is a Preference Assessment Survey / Reinforcer Assessment Survey. It is a questionnaire to help you discover a student's preferences and possible reinforcers.
Categories include: Social, Sensory, Indoor Activities, Outdoor Activities, Video, Books, Animals, Strengths/Interests, TV, Computer, Video Games, Music, and Dislikes.
Typically, I give this to the parents during the first week of school every year, because student interests change often.
Following the survey, then you can do a preference Assessment / Reinforcer Assessment directly with the student to find the most preferred activities. These may be used as reinforcers for positive behaviors.