Student name:______
SpecialSchool District
DATA GATHERING CHECKLISTS
Supplements to the SSD Data Gathering Packet
A - Intervention Documentation
(Must be completed unless Building Level Team has alternative method of documentation)
B - Optional Motor Checklist
C - Optional Adaptive Behavior Checklist
D - Optional Social/Emotional/Behavioral Checklist
E - Optional Task Related Behaviors Checklist
(All “Optional” checklists may be completed when determined necessary by Building Level Team)
A - INTERVENTION DOCUMENTATION
Use of this form is optional if building team has alternative documentation
Academic Interventions
Intervention #1 / Intervention #2 / Intervention #3 / Intervention #4Description of intervention
Length of Intervention
Progress monitoring (Include both how and how often)
Behavior Interventions
Intervention #1 / Intervention #2 / Intervention #3 / Intervention #4Did the behavior improve?
Describe level
of current behavior in relation to peers
Attach graph(s) of results.
Can the interventions be continued? ___ Yes ___ No
If no, explain:______
______
______
Is a request for consideration of a special education evaluation needed? ___ Yes ___ No
If yes, explain why:______
______
______
What questions would you want a special education evaluation to answer?
1.______
______
2.______
______
3.______
______
4.______
______
5.______
______
6.______
OPTIONAL
B - MOTOR CHECKLIST
Please complete this checklist when significant motor deficits exist in comparison to same age peers
Directions: Check all behaviors that you have observed while the student was in your presence
Preferred handrightleft dominance not established mixed dominance
Preferred foot rightleft dominance not established mixed dominance
Does student demonstrate significant::
Excessive activity level Difficulty participating in organized group activities
Difficulty initiating movement Withdrawal when touched or moved
Uncoordinated movements Distraction with visual stimuli
Excessive effort with motor tasks Distraction with auditory stimuli
Difficulty maintaining dynamic balance Difficulty maintaining static balance
Tendency to bump into walls/classmates Difficulty maintaining an erect sitting posture
Difficulty with eye-hand coordination Confusion of left - right
Confusion with spatial or directional concepts Difficulty with eye-foot coordination
Difficulty following sequence of motor movements Difficulty imitating position/movement
Need for support when walking around classroom or on stairs
GROSS MOTOR
Child demonstrates significant difficulties in comparison to same age peers with:
Side stepping/sliding Running Hopping on one foot Jumping
Skipping Galloping Walking Elementary tumbling
Climbing apparatus Striking an object Kicking an object Throwing object
Kicking Hopscotch Flexibility Individual jump rope
Endurance Muscular strength Speed Agility
Catching an object with hands
FINE MOTOR
Child demonstrates significant difficulties in comparison to same age peers with:
Coloring within lines Cutting on line PrintingCopying words
Knowing left/right on self Writing in cursive Holding paper still while
coloring or writing
SELF CARE
Child demonstrates significant difficulties in comparison to same age peers with:
Dressing Buttoning Tying shoes Zipping coat/trousers
Toileting Carrying lunch tray without spilling Holding fork/spoon with
mature grasp
Comments:______
______
______
Person completing form:______Date:______
OPTIONAL
C - ADAPTIVE BEHAVIOR CHECKLIST
Please complete this checklist when significant adaptive behavior deficits exist in comparison with same age peers.
Directions: Check all behaviors that you have observed while the student was in your presence
Self-Help Skills
difficulty taking care of toileting needs
difficulty tying or fastening shoes
difficulty fastening articles of clothing
does not demonstrate appropriate hygiene/grooming
does not demonstrate appropriate mealtime behavior
difficulty choosing clothing appropriate to weather condition
difficulty taking care of personal property
does not demonstrate necessary mobility to participate in leisure/recreational activities
Environmental Skills
does not comprehend graphic symbols and signs
does not demonstrate ability to navigate the school grounds
does not seek assistance when appropriate
does not demonstrate knowledge of requirements for personal safety
does not understand the concept of time
does not understand the concept of measurement
Interpersonal Skills
does not demonstrate age appropriate school interactions
does not respond appropriately in a group setting
does not interact appropriately in a group setting
does not respond appropriately to environmental social cues
does not respond appropriately to the feelings of others
does not display the apropriate interaction with strangers
difficulty taking turns when appropriate
difficulty in making choices during leisure activities
Communication Skills
difficulty comprehending verbal communication
difficulty providing relevant verbal responses to conversation
does not communicates name, address and phone number
does not uses verbal skills to convey information and interact
Comments:______
______
______
Person completing form:______Date:______
OPTIONAL
D - SOCIAL/EMOTIONAL/BEHAVIORAL CHECKLIST
Please complete this checklist when significant social/emotional/behavioral deficits exist in comparison to same age peers
Directions: Rate the frequency of the listed behaviors that you have observed while the student was in your presence (monthly, weekly, daily, or hourly).
MonthlyWeeklyDailyHourly
1.Talks out without raising hand.
2.Makes noises which disturb others (humming, mumbling,
snapping fingers,drumming pencils, etc.)
3.Does not participate in classroom activities. 4. Leaves seat without permission.
5.Leaves room without permission.
6.Leaves school without permission.
7.Is late to school.
8.Is tardy to class.
9.Uses abusive or inappropriate language
10.Complains of physical discomfort.
11.Continues a behavior when it is nolonger appropriate. 12. Demonstrates involuntary physicalreactions (shaking,
twitching, etc.)
13.Engages in self-destructive behaviors (e.g.,scratches or bites
self, temper tantrums)
14.Engages in unnecessary movements inseat or out of seat. 15. Reacts negatively when touched.
16.Cries easily.
17.Demands immediate response from others
18.Denies inappropriate behaviors.
19.Blames others for mistakes.
20.Acts impulsively.
21.Engages in self-stimulating behaviors (e.g.,twirling objects,
thumb sucking, etc.)
22.Engages in inappropriate sexually-related behaviors (please
explain incomment section if a concern).
25.Blames self for situations beyond his/her control.
26.Threatens to hurt self or commit suicide(verbally, in writing,
or in pictures).
27.Does not smile, laugh, or demonstrate happiness.
28.Is pessimistic (thinks nothing will turn out right).
29.Is overly self-critical in regard toschool related abilities,
personal appearance, etc.
30.Is apathetic and unmotivated.
31.Becomes pale, may throw up, or passout when anxious or
frightened.
32.Demonstrates phobic type reaction.
33.Speaks incoherently (disconnected, unrelated,bizarre, or
unintelligible statements)
MonthlyWeeklyDailyHourly
34.Indicates that no one likes or cares about him/her.
35.Talks back
36.Is physically aggressive towards peers.
37.Is physically aggressive towards authority figures.
38.Physically threatens peers.
39.Physically threatens authority figures.
40.Gets into fights with students.
41.Verbally threatens other students.
42.Verbally threatens authority figures.
43.Makes inappropriate gestures to students
44.Makes inappropriate gestures to authority figures.
45.Throws objects.
46.Prefers one-to-one relationships ratherthan involvement with
a group.
47.Prefers to be alone in social settings.
48.Teases other students.
49.Is teased by other students.
50.Is isolated by other students.
51.Seeks excessive physical attention from others (needs hand
held, hugs, etc.)
52.Responds inappropriately to corrections.
53.Responds inappropriately to comments from others.
54.Responds inappropriately to praise and/orrecognition from
others.
55.Takes property belonging to others.
56.Abuses property belonging to others.
57.Has difficulty keeping hands and feet to self.
58.Reacts inappropriately in competitive situations.
59.Reacts inappropriately to the success of others.
Comments:______
______
______
Person completing checklist:______Date:______
OPTIONAL
E - TASK RELATED BEHAVIORS CHECKLIST
Please complete when significant task orientation deficits exist in comparison to same age peers
Directions: Rate the frequency of the listed behaviors that you have observed while the student was in your presence (monthly, weekly, daily, or hourly).
MonthlyWeekly Daily Hourly
1. Has difficulty organizing or appropriately using necessary materials.
2. Has difficulty organizing or appropriately using time.
3. Demonstrates difficulty or reluctant in beginning tasks.
4. Has difficulty staying with task.
5. Performs school work in a careless manner when handwriting skills appear
adequate or better.
6. Needs directions/lessons repeated
7. Requires one-to-one instruction
8. Rushes through work.
9. Works slowly
10. Does not complete class assignments.
11. Does not complete homework.
12. Completes work at a failing level
13. Requires additional time to complete work.
14. Draws/doodles at inappropriate times
15. Daydreams/stares away from task
16. Has difficulty making transition from one activity to another.
17. Destroys/throws away work.
18. Has difficulty working independently.
19. Has difficulty working in a group setting
20. Socializes at inappropriate times.
Comments:______
______
______
Person completing checklist:______Date:______
8/06