no. i.] PSYCHOLOGICAL EXAMINING IN THE UNITED STATES ARMY. 



PERFORMANCE SCALE EXAMINATION 



275 



Name- 



Company — 

 Where born_ 



...Regiment-. 



Previous occupation 



Education : Grade _ 



Where educated. - 



Language ability .. 



Disease history, personal and family 



Total score. 



Remarks _. 



.Age Race 



Arm., _ -.-Division.- 



Years in U. S 



Weekly wages 



-JH. S . College.... 



_ _ _ Years in school 



...Percentile rank... 



.Rating.. 



Examiners report — 

 Examiner 



__Date.. 



1. Ship Test (5 min.) 



3. Cube Imitation 



Response 



+ or — 



■ "Score Wtd. Sc 



■(«) 

 0>) 

 («) 



w 



CO 



(g) 



W 



(0 



1-2-3-4 



1-2-S-4-S— _ 



2-3-4-1 



1-3-2-1 



l-S-1-2-4... 

 1-4-3-2-4. __ 

 1-3-2-4-1-3. 

 1-4-2-3-4-1. 

 1-4-3-1-4-1.. 

 2-3-1-2-4-2. 



S. Form Board 



Division of Psychology, Medical Department, U. S. A.. Authorized by the Surgeon General, Feb. 23, 1918. 



Edition, Mar. 6, 1918, 20,000. 



Fig. 73.— Performance Scale Examination (first page). 



