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Directions: For each item, place a check in the appropriate column
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Rarely |
Sometimes |
Always |
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Communication: |
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| 1. |
Follows two step unrelated directions. (Put the toy up and get a book.) |
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| 2. |
Identifies at least 3 objects from broad range of categories (i.e. animals, food). |
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| 3. |
Identifies objects by the sounds they make (door shut, coin drop, water running). |
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| 4. |
Articulates clearly, speech intelligible 80% of the time. |
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| 5. |
Asks simple questions. |
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| 6. |
Comments on story when being read to --describes action, asks questions. |
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| 7. |
Spontaneously uses sentences of 3-5 words. |
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| 8. |
Tells first and last name upon request. |
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| 9. |
Knows siblings and friends names. |
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| 10. |
Knows words to short song or rhyme. |
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Cognitive Skills: |
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| 1. |
Points to 3 shapes--circle, square, triangle. |
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| 2. |
Points to primary colors--red, blue, yellow, green |
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| 3. |
Counts by rote to 10. |
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| 4. |
Demonstrates concept of one and one more. |
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| 5. |
Demonstrates concept of more or less. |
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| 6. |
Completes simple form board. |
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| 7. |
Looks at books, turning one page at a time, talking about story / picture. |
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| 8. |
Imitates simple block design produced by teacher (3 part bridges, 5 color train). |
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| 9. |
Engages in symbolic play (chair used as car, can used as hat). |
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| 10. |
Participates during large group activities (circle, art project, lunch). |
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Social / Emotional: |
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| 1. |
Gives name of friend. |
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| 2. |
Follows rules without being reminded. |
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| 3. |
Takes turns with peers with adult supervision. |
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| 4. |
Meets unfamiliar adults comfortably. |
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| 5. |
Is helpful to adults and peers. |
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| 6. |
Plays cooperatively with peers with adult help. |
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| 7. |
Can express feelings verbally--say when happy, sad, afraid, angry. |
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| 8. |
Is a friendly, happy child. |
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| 9. |
Shows affection toward others, sympathy if someone is hurt. |
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| 10. |
Seeks help when experiencing difficulty, when sad, hungry... |
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Self-Help Skills: |
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| 1. |
Uses spoon and fork to eat. |
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| 2. |
Uses napkin to wipe mouth spontaneously. |
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| 3. |
Undresses self independently. |
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| 4. |
Indicated need to use the toilet. |
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| 5. |
Toilets independently. |
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| 6. |
Uses tissue to wipe nose. |
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| 7. |
Operates large buttons and zippers on own clothing. |
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| 8. |
Pours from a small pitcher into a cup. |
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| 9. |
Washes hands with soap and dries hands. |
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| 10. |
Puts on own coat. |
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Fine and Gross Motor Skills: |
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| 1. |
Stands on right foot for 4 seconds. |
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| 2. |
Walks downstairs alternating feet. |
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| 3. |
Stands on left foot for 4 seconds. |
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| 4. |
Stacks 10 or more one inch blocks. |
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| 5. |
Copies horizontal and vertical lines. |
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| 6. |
Draws a circle. |
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| 7. |
Copies a cross. |
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| 8. |
Hops 5 feet. |
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| 9. |
Walks on tiptoe. |
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| 10. |
Throws ball forward. |
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