Please tell us about how much you assist your child with the following activities; check the

box that best describes your child’s TYPICAL performance:

COMPLETES ON OWN
NOT COMPLETED/NO

GET CHILD SET UP OR

REMINDED/TOLD TO
MOST/APPROX. 75%

SAFETY AND/OR TO
ONLY HELP IF THEY
I DO THIS TASK OR
OPPORTUNITY TO

SOME/LESS THAN
HELP CHILD WITH

HELP CHILD WITH

HELP CHILD WITH

BUT TAKES THEM

AVOIDS/REFUSES

SUPERVISED FOR

INDEPENDENTLY
KEEP ON TASK
APPROX. 50%

NEEDS TO BE

COMPLETES
NEARLY ALL

COMPLETE
STRUGGLE
STARTED

LONGER
HALF
Use fork to eat

Use spoon to eat

Use a knife to cut

EATING & MEAL PREPARATION

Use a knife to spread

Drink from a straw

Drink from an open cup

Pour half gallon of milk

Open a jar that has already been

opened
Clear dishes from table

Prepare simple food requiring mixing

Comb hair

Take a bath/shower and dry self

HYGIENE

Successful with toilet training during

the day & night
Clean self after toileting

Wash/dry hands thoroughly

 FASTENERS DRESSING

Put on coat

Put on socks

Put shoes on
Take off shirt

Tie shoelaces
Take off socks

Take shoes off

Button buttons
Open/Close Snap
Open/Close Velcro
Put on pull-over shirt

Put on pants/underwear

Put shoes on correct feet

Take off pants/underwear

Fasten zipper at bottom and zip

Orientate clothing (front/back; right-side out)
NOT COMPLETED/NO
OPPORTUNITY TO

AVOIDS/REFUSES

I DO THIS TASK OR
NEARLY ALL

HELP CHILD WITH

MOST/APPROX. 75%

HELP CHILD WITH

APPROX. 50%

HELP CHILD WITH

SOME/LESS THAN

GET CHILD SET UP OR

STARTED

ONLY HELP IF THEY

STRUGGLE

SUPERVISED FOR
SAFETY AND/OR TO

NEEDS TO BE
REMINDED/TOLD TO

COMPLETES ON OWN
BUT TAKES THEM

COMPLETES
INDEPENDENTLY
 HOME, COMMUNITY, & SCHOOL

routine

are speaking to
Write with a pencil

Run short distances

more than 5 minutes

Pay attention in class

Control voice volume

Color inside of the lines

Accept unexpected changes in

Walk up stairs, alternating feet

Play cooperatively with a child for

Change from one activity to another

Make eye-contact with someone they

NOT COMPLETED/NO
OPPORTUNITY TO

AVOIDS/REFUSES

I DO THIS TASK OR
NEARLY ALL

HELP CHILD WITH

MOST/APPROX. 75%

HELP CHILD WITH

APPROX. 50%

HELP CHILD WITH

SOME/LESS THAN

GET CHILD SET UP OR

STARTED

ONLY HELP IF THEY

STRUGGLE

SUPERVISED FOR
SAFETY AND/OR TO

NEEDS TO BE
REMINDED/TOLD TO

COMPLETES ON OWN
BUT TAKES THEM

COMPLETES
INDEPENDENTLY