Checklist on Learning and Behavior Characteristics

(CLBC)
Name of the Child:
_____________________________________________________________
Birthday: ______________________________________________Age:
___________________
Grade level: ________________________________Date
Observed:______________________
Current classification:
___________________________________________________________
Educational Placement/Program:
_________________________________________________
Observer:___________________________________________________________________
__

Directions: You will be asked to evaluate the child objectively based on your
observation and interactions with him/her. The child will be rated each
item by checking under the column.

Characteristics Sometimes Most Of All Of The

The Time Time
(1 point) (2 Points) (3 Points)
I. LEARNING ABILITY
A. Spelling
1. Uses incorrect letter order

2. Cannot spell correctly at grade

level
3. Cannot write from dictation at
grade level
4. Reverse letters or entire words

B. Writing
1. Cannot write name or other
information
2. Cannot stay on line

3. Cannot copy simple sentences

from the board
4. Cannot write simple sentences
from dictation
5. Cannot do regular work in writing
for grade level
C. Reading
1. Does not like to read

2. Loses place when reading

3. Repeat, omits or adds words

4. Cannot read the DOLCH Sight

Words for grade level
5. Uses fingers to follow a line

6. Cannot understand/remember
what he/she reads
D. Mathematics
1. Has difficulty associating
numbers with symbol

2. Reverse two-place numbers (e.g.

13 for 31 or vice versa)
3. Cannot recall math facts at grade
level
4. Fails to comprehend math
concepts
5. Gets confused with written and/or
oral arithmetic
6. Cannot identify shapes, sizes and
colors of objects
E. Hearing/Speech
1. Does not seem to listen when
spoken to
2. Cannot follow oral direction

3. Has articulation problems; wrong

pronunciation of words; speech
not clear
4. Has infantile (baby) speech

F. Psychomotor
1. Displays poor motor coordination
in using scissors, crayons, pencil,
etc.
2. Confuses right from left
 3. Lacks rhythm in movement; loses
sequence and balance; has
difficulty walking in straight line

4. Has difficulty buttoning, zipping,

and snapping articles of clothing
5. Has difficulty jumping, hopping,
running, skipping, climbing
II. BEHAVIOR CHARACTERISTICS
1. Tends to be impulsive; hits
classmates; reacts immediately
to situations without thinking;
impatient; cannot wait for his/her
turn
2. Demands individual attention
through overt behavior tactics
3. Rushes through assignments
(written tasks) with little or no
regard for accuracy, quality of
work and neatness
4. Does not direct attention to or
cannot maintain attention to
important sounds in the
immediate environment, teacher’s
directions, public addresses, etc.
5. Has short attention span; has
difficulty concentrating on tasks
(e.g. more interested in other
activities, sits and does nothing)
6. Stays out of seat; engages in over
active behavior

TOTAL

_______________________________
Name and Signature of Observer/Evaluator
Date accomplished: ___________________
Hand Phone Number: _________________
E-mail Address: _____________________