listening in large group / difficulty repeating directions: simple
participation in large group / difficulty repeating directions: complex
sustained attention / difficulty repeating directions: delay
memory/retention / difficulty recalling information
homework completion / difficulty w/ instructional sequences
cognitive shift/flexibility / difficulty recalling details: auditory
organizational skills / difficulty recalling details: visual
anxiety / difficulty recalling order :first
impulsive/ lack of inhibition / difficulty recalling order: middle
risk taking / difficulty following class procedures
work completion / difficulty recalling usual details: aud.
social skills/friendships / difficulty recalling usual details: visual
low frustration level / long term memory concerns
learns poorly: auditory channel / memorization of rote facts: auditory
work accuracy
language processing concerns / memorization of rote facts: visual
difficulty listening: large group / thinking/reasoning concerns
difficulty listening : small group / difficulty solving problems
difficulty listening: 1:1 / difficulty understanding cause/effect
difficulty with age appropriate vocabulary / difficulty reading non-verbal cue
difficulty with directions : simple / difficulty with abstract concepts
difficulty with directions: complex / difficulty generalizing concept
difficulty with complex: language / reading concerns
difficulty paraphrasing/summarizing / decoding/word attack
difficulty answering questions accurately / phonics
difficulty retelling stories / fluency
needs extra wait time / comprehension
difficulty localizing sounds / sight words
confuses sounds/words with others / vocabulary
difficulty with abstract language/fig / math concerns
difficulty maintaining relevancy/discussion / difficulty using space
difficulty w/ immediate recall / difficulty with visual relationships ($)
difficulty w/ immediate recall: delayed / difficulty aligning numbers
sustained attention concerns / writing concerns
difficulty following directions/transitions / no recog. error patterns/length OK
doesn’t pay attention to detail visual / difficulty with handwriting
doesn’t pay attention to detail auditory / difficulty copying
loses train of thought while talking / difficulty planning/formulating ideas
needs constant prompts to complete work / difficulty with organization and content
gets started but loses focus during task / difficulty with spelling (describe errors:
easily distracted noise / difficulty sound words out
easily distracted visuals / words have B/E sounds/mid errors
easily distracted items w/in reach / words have error patterns: vowels
day dreams/stares off / words have error patterns: cons
difficulty following directions/transitions / difficulty with handwriting
doesn’t pay attention to detail visual
Student’s Name: ______School: ______Date: ______
Evaluators: ______
CLASSROOM PERMORMANCE IMPACT QUESTIONNAIRE SUMMARY
(list subject or teacher initial in top of column on each page)
classroom concerns / working memorylistening in large group / difficulty repeating directions: simple
participation in large group / difficulty repeating directions: complex
sustained attention / difficulty repeating directions: delay
memory/retention / difficulty recalling information
homework completion / difficulty w/ instructional sequences
cognitive shift/flexibility / difficulty recalling details: auditory
organizational skills / difficulty recalling details: visual
anxiety / difficulty recalling order :first
impulsive/ lack of inhibition / difficulty recalling order: middle
risk taking / difficulty following class procedures
work completion / difficulty recalling usual details: aud.
social skills/friendships / difficulty recalling usual details: visual
low frustration level / long term memory concerns
learns poorly: auditory channel / memorization of rote facts: auditory
work accuracy
language processing concerns / memorization of rote facts: visual
difficulty listening: large group / thinking/reasoning concerns
difficulty listening : small group / difficulty solving problems
difficulty listening: 1:1 / difficulty understanding cause/effect
difficulty with age appropriate vocabulary / difficulty reading non-verbal cue
difficulty with directions : simple / difficulty with abstract concepts
difficulty with directions: complex / difficulty generalizing concept
difficulty with complex: language / reading concerns
difficulty paraphrasing/summarizing / decoding/word attack
difficulty answering questions accurately / phonics
difficulty retelling stories / fluency
needs extra wait time / comprehension
difficulty localizing sounds / sight words
confuses sounds/words with others / vocabulary
difficulty with abstract language/fig / math concerns
difficulty maintaining relevancy/discussion / difficulty using space
difficulty w/ immediate recall / difficulty with visual relationships ($)
difficulty w/ immediate recall: delayed / difficulty aligning numbers
sustained attention concerns / writing concerns
difficulty following directions/transitions / no recog. error patterns/length OK
doesn’t pay attention to detail visual / difficulty with handwriting
doesn’t pay attention to detail auditory / difficulty copying
loses train of thought while talking / difficulty planning/formulating ideas
needs constant prompts to complete work / difficulty with organization and content
gets started but loses focus during task / difficulty with spelling (describe errors:
easily distracted noise / difficulty sound words out
easily distracted visuals / words have B/E sounds/mid errors
easily distracted items w/in reach / words have error patterns: vowels
day dreams/stares off / words have error patterns: cons
difficulty following directions/transitions / difficulty with handwriting
doesn’t pay attention to detail visual
Student’s Name: ______School: ______Date: ______
Evaluators: ______
CLASSROOM PERMORMANCE IMPACT QUESTIONNAIRE SUMMARY
CPI Questionnaire Summary-Page 2 Name:______
metacogntion concerns / emotional reg/self cont/ inhibitionunaware when not understanding inst. / becomes easily upset
unaware when not foll. dir. accurately / acts impulsively (verb/phys)
gets stuck on one approach/solution / interrupts others
unaware of resources/ways to seek help / difficulty waiting for turn
doesn’t attempt resolve prob./waits / anxious
doesn’t check or edit work
task initiation concerns / time management concerns
difficulty getting started but completes task / diff .breaking assign. into smaller steps
needs redirection can’t repeat / difficulty developing a timeline (plan)
needs redirection can repeat/doesn’t start / difficulty finishing task in time given
diff. start task w/ incomplete previous task / difficulty using time efficiently
diff. following directions during transitions / gets started/ loses focus during task
watches peers for additional cues to begin / environnmental issues
needs assurance to start-risk taking / poor acoustics
waits for redirection before starting / portable
organization concerns / adjacent noisy classroom
diff .remembering to write assign. down / poor acoustics
difficulty tracking assignments / number students
difficulty remembering order/sequence / Effective strategies/accom.
diff. finding materials (misses directions)
difficulty with home/school communication
diff. keep belongings neat/approp. place
difficulty keeping backpack organized
strengths
Donna Massine C 2009