FUNCTIONAL SKILLS CHECKLIST

Adapted from various inventories including the Brigance

Student: Grade: Date:

Teacher:

1. Motor Skills *Also see Occupational Therapy Report, if available

Personal Care / Self Help:

Dressing:
⃞ Takes shoes / boots off ⃞ Puts shoes / boots on
⃞ Takes jacket off ⃞ Puts jacket on
⃞ Takes backpack off ⃞ Puts backpack on – with some assistance

Fastening:
⃞ Manages large front buttons ⃞ Attempts to tie shoes
⃞ Velcros shoes closed ⃞ Ties shoes
⃞ Zips up front zipper

Eating:
⃞ Feeds self snacks ⃞ Lifts cup or glass from table
⃞ Spoon feeds without spilling ⃞ Opens containers
⃞ Puts left over food away (garbage or back into containers)

Toileting:
⃞ Knows when he/she needs to go and communicates this in some way
⃞ Needs help with all clothing
⃞ Pulls down pants
⃞ Attempts to wipe self
⃞ Cares for toileting needs other than help for wiping
⃞ Flushes toilet
⃞ Manages clothes adequately on own
⃞ Needs standby help

Fine Motor
⃞ Manipulates small toys / items (large lego, toy figurines...)
⃞ Puts items together (building blocks, interlocking blocks, large puzzles...)
⃞ Scribbles ⃞ Scribbles – seldom going off page
⃞ Traces lines ⃞ Traces some letters
⃞ Traces circles ⃞ Traces name
⃞ Copies some shapes ⃞ Copies some letters
⃞ Copies name ⃞ Colors simple shapes, mostly within the
lines
2. General Knowledge and Comprehension

Personal Data
⃞ First name
⃞ Full name
⃞ Sex
⃞ Age
⃞ Siblings

Vocabulary: Matching

Body Parts: Pointing To (Receptive) / Naming (Expressive)

1. mouth 6. tongue 11. arms 16. chin

2. eyes 7. head 12. fingers 17. tongue
3. nose 8. ears 13. stomach / tummy 18. hair
4. feet 9. hands14. back
5. toes 10. legs 15. teeth

Colours: Pointing To (Receptive) / Naming (Expressive)

1. red 3. green 5. orange 7. brown
2. blue 4. yellow 6. purple 8. black

Shape Concepts: Pointing to (Receptive) / Naming (Expressive):

1. circle
2. square
3. triangle

Quantitative Concepts
1. one / many 2. little / big

Directional / Positional Concepts

1. open / close 3. in / out 4. behind / in front of
2. front / back 4. up / down 6. over / under

Sorting / Classifying
1. Colours
2. Shapes
3. Animals
4. Toys
5. Cars / trucks
Readiness

Recites Alphabet

Recognizes Letters
Receptive:
Upper Case -
Lower Case -
Expressive
Upper Case -
Lower Case -

Word Recognition:
Approximate Grade Level -
Or
Estimated Number of Sight Words that student recognizes -

Reads Colour Words:

Reads Number Words:

Reads Calendar Words (days, months):

Reads Common Signs:

Go Stop In Out Boys Girls Exit Enter Men Women

Walk Wait Caution Danger

Literacy Skills:

⃞ Looks at books – right side up

⃞ Turns pages individually
⃞ Points to specific pictures on request
⃞ Names pictures
⃞ Takes part in read by ‘filling in’ words and phrases
⃞ Tries to read book from memory

Printing:

First Name:

Age:

Last Name:

Phone Number:

Lower Case Letters Dictated:

 Upper Case Letters Dictated:

Simple Sentence:

Arithmetic:

Counts Objects to: ___________ Rote Counts to: ___________

Reads Numerals to (estimated):

Numeral Comprehension (matches quantity) to

Writes Numbers in Sequence to

Writes Numerals Dictated

Addition Combinations to

Subtraction Combinations to

Recognition of Money:

Tells Time:
FUNCTIONAL SKILLS SUMMARY FORM

Student: Date:

Personal Care / Self Help Skills to be worked on

1
2
3
4

Fine Motor Skills to work on…. please consult with OT/PT

1
2
3
4

Gross Motor Skills to work on…. please consult with OT/PT

1
2
3
4

Personal Knowledge…. Name, age, family members… to be learned

1
2
3
4

Early Learning - including Vocabulary and Concepts (objects, colours, etc) to be worked on
1
2
3
4
5

Functional Academics…. Early Literacy and Numeracy Skills to be worked on

1
2
3
4

Communication Skills to be worked on (consult SLP)

1
2
3
4

Assistive Technology Skills to be worked on (consult SET-BC)

1
2
3
4

Home and School Safety Skills to be acquired

1
 2
3
4

Neighborhood Awareness and Safety to be acquired

1
2
3
4

Leisure Skills to be acquired

1
2
3
4

Community Awareness and Safety to be acquired

1
2
3
4