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Iour-ear-C|d Ch||d Data Sheet for the 8kIGANCL reschoo| Screen
A. Ch||d Data ?ear MonLh uay
Chlld's name ________________________ uaLe of Screenlng
arenLs/Cuardlan ____________________ 8lrLhdaLe
Address ____________________________ Age
8. 8as|c Screen|ng Assessments C. Ch||d's Score
Sk||| (C|rc|e the sk||| for each correct response. Make notes as appropr|ate.) 8esponses olnL value
1. flrsL name 2. lasL name 3. mlddle name 4. age x 1 polnL each
1. Lhumbs 2. Loes 3. neck 4.sLomach
3. chesL 6. back 7. knees 8. chln
9. flngernalls
1. SLands on one fooL 2. Walks LlpLoe four sLeps
3. Walks forward heel-and-Loe four sLeps
1. sLove 2. coaL 3. car x 3 polnLs each
kepeats Sentences of: 1. four syllables 2. slx syllables 3. elghL syllables x 3 polnLs each
1. Lwo 2. Lhree 3. flve x 3 polnLs each
1. 6 blocks 2. 7 blocks 3. 8 blocks 4. 9 blocks
3. 10 blocks
1. red 2. blue 3. green 4. yellow 3. orange x 2 polnLs each
1. boaL 2. klLe 3. wagon 4. ladder
3. sclssors 6. leaf
D. Cbservat|ons
1. Pandedness: 8lghL_____ LefL _____ uncerLaln ______ I. kecommendat|ons
2. Crasps encll WlLh: llsL ______ llngers _______
3. Pearlng appeared Lo be normal:
?es______ no _______ uncerLaln __________
4. vlslon appeared Lo be normal:
?es______ no _______ uncerLaln __________
3. 8ecord oLher observaLlons below
repos|t|ons and Irregu|ar
ronouns:
1. reposlLlons 2. lrregular ronouns
2 polnLs each
1ota| score= ]100
x 3 polnLs each
1e||s use of:
Number of Concepts:
Ident|f|es Co|ors:
|cture Vocabu|ary: x
8u||ds 1ower w|th 8|ocks: x 2 polnLs each
V|sua| Motor Sk|||s: (cop|es) 1. ___________ 2. 3. x 3 polnLs each
rogram_______________________________
1eacher _______________________________
Lxamlner ______________________________
Gross Motor Sk|||s:
x
x
3 polnLs each
ersona| Data kesponse:
Ident|f|es 8ody arts:
1 polnL each