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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 three step unrelated directions. |
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| 2. |
Understands prepositions--in, on, in front, behind. |
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| 3. |
Receptively identifies red, black, yellow, blue. |
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| 4. |
Responds to "wh" questions--who, what, where, when, why. |
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| 5. |
Recites and sings simple songs and rhymes. |
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| 6. |
Articulates clearly, speech is 90% intelligible. |
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| 7. |
Average length of sentence or response is 5 words. |
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| 8. |
Knows what words sound the same or different (light-right). |
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| 9. |
Names colors--red, black, yellow and blue. |
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| 10. |
Asks "wh" questions--who, what, where, when, why. |
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Cognitive Skills: |
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| 1. |
Names circle, square and triangle. |
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| 2. |
Attends to task for 10 minutes. |
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| 3. |
Knows name of city and street address. |
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| 4. |
Points to chest, ankle, jaw. |
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| 5. |
Counts 2 items or gives 2 items upon request. |
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| 6. |
Categorizes objects (dog is an animal, airplane is a thing we ride). |
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| 7. |
Recognizes first name in print. |
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| 8. |
Recognizes labels (i.e. McDonalds, Power Rangers). |
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| 9. |
Looks at books and listens to stories showing comprehension. |
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| 10. |
Counts by rote to 15. |
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Social / Emotional: |
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| 1. |
Names favorite television shows. |
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| 2. |
Follows rules without being reminded. |
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| 3. |
Shows concern or sympathy towards others. |
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| 4. |
Is aware of good and bad behavior. |
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| 5. |
Tries new games, tasks easily. |
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| 6. |
Takes turns with peers without adult supervision. |
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| 7. |
Plays with toys independently and appropriately. |
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| 8. |
Speaks spontaneously during all activities. |
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| 9. |
Answers telephone and summons correct person. |
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| 10. |
Waits turn in games. |
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Self-Help Skills: |
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| 1. |
Is cautious crossing street. |
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| 2. |
Undresses self independently. |
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| 3. |
Pulls shirt over head independently. |
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| 4. |
Buttons, zips, snaps independently. |
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| 5. |
Washes hands and face independently. |
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| 6. |
Brushes teeth independently. |
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| 7. |
Pours from a small pitcher. |
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| 8. |
Indicates likes and dislikes of food. |
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| 9. |
Wipes self thoroughly after toileting. |
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| 10. |
Willingly assists with classroom chores. |
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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. |
Copies horizontal and vertical lines. |
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| 3. |
Walks downstairs alternating feet. |
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| 4. |
Stands on left foot for 4 seconds. |
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| 5. |
Stacks 12 or more one inch blocks. |
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| 6. |
Copies an "X" |
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| 7. |
Throws a ball overhand. |
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| 8. |
Draws a man with at least 3 parts. |
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| 9. |
Pedals and steers a tricycle. |
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| 10. |
Spreads with a knife (i.e. peanut butter on cracker). |
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