Distraction index form

_______________________
Name

DISTRACTION INDEX FORM

Activity: _____________________________

Day 1. Date: ______________ Beginning time: ________ Ending time: _________

Day 2. Date: ______________ Beginning time: ________ Ending time: _________

Day 3. Date: ______________ Beginning time: ________ Ending time: _________

Day 4. Date: ______________ Beginning time: ________ Ending time: _________

Day 5. Date: ______________ Beginning time: ________ Ending time: _________