Language
English (US)
Russian
Name of the Child being evaluated
*
First Name
Last Name
Today's date
*
-
Month
-
Day
Year
Date
Child's date of birth
*
-
Month
-
Day
Year
Month, day, and year
Parent/Caregiver's legal name
*
First Name
Last Name
Number of siblings the child has at home.
Please Select
None
1
2
3 or more
What is your relationship to the child you are rating
*
Parent
Guardian
Other (describe below)
Please describe your relationship to the child you are rating
ABAS-3
Parent-Primary Caregiver (Age 0-5)
Instructions: Read through this entire packet and indicate if the child that you are rating is able to do the different items that are listed. A 3 indicates that the child can do the task with no issues or help; a 2 means they need a little help; a 1 means they need a lot of help to do the task, and a 0 means they do not do it by them self at all. Some of the things they may not be able to do yet, indicate that as 0.
If you have any questions please email jotforms@sabintn.com
Child's Name
*
First Name
Last Name
Name of person filling out this form
*
First Name
Last Name
Communication
Instructions: Read through this entire packet and indicate if the child that you are rating is able to do the different items that are listed. A 3 indicates that the child can do the task with no issues; a 2 means they need a little help; a 1 means they need a lot of help to do the task, and a 0 means they do not do it by them self at all. Some of the things they may not be able to do yet, indicate that as 0.
1. Looks at other people's faces when they are talking to him or her.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
2. Looks up or smiles when someone says his or her name.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
3. Laughs when a parent or other person laughs.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
4. Raises and lowers voice to express different feelings or needs.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
5. Says the names of other people (for example, "Mama," "Daddy," or names of friends).
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
6. Follows simple commands (for example, ''No" or "Come here").
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
7. Uses one or more words to get something he or she wants, even if the word is not said correctly or pronounced well.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
8. Shakes head or says "Yes" or "No" in response to a simple question (for example, "Do you want something to drink?").
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
9. Points to common items in a room when asked (for example, "Show me the TV").
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
10. Repeats words others say (for example, says "baby" when an adult says "baby").
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
11. Says phrases with at least two words (for example, "My book").
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
12. Says the name of an object clearly enough that others recognize it (for example, "ball," "dog," "cup").
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
13. Listens closely for at least 1 minute when people talk.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
14. Speaks clearly enough that others who do not know him or her can understand most of what is said.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
15. Follows simple, one-step directions that include "over" or "under" (for example. "Put your hands over your head").
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
16. Refrains from repeating what he or she says over and over again.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
17. Names 20 or more familiar objects.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
18. Sings all or part of the words to songs.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
19. Makes plurals of words by adding an -s (for example, "shoes," "socks," "dogs").
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
20. Uses sentences with a noun and verb.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
21. Tells parent, friends, or others about his or her favorite activities.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
22. Asks questions such as "Will you play with me?"
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
23. Speaks in sentences of six or more words.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
24. Uses past tense to talk about prior events (for example, "I stayed inside").
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
25. Has a conversation with another person for at least 3 minutes.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
26. Waits for others to finish what they are saying, without interrupting.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
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Community Use
Do not complete this skill area if the child being rated is younger than 1 year old. Instructions: Read through this entire packet and indicate if the child that you are rating is able to do the different items that are listed. A 3 indicates that the child can do the task with no issues; a 2 means they need a little help; a 1 means they need a lot of help to do the task, and a 0 means they do not do it by them self at all. Some of the things they may not be able to do yet, indicate that as 0.
1. Stays with parents or other family members in a store and does not wander off.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
2. Recognizes own home in his or her immediate neighborhood.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
3. Walks on sidewalk rather than street.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
4. Informs parents when someone comes to the door.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
5. Shows respect for public property (for example, throws trash in cans, does not damage property).
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
6. Obeys an adult's request to "don't touch" items when shopping.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
7. Asks to go to a park or other favorite community place.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
8. Knocks on a door or rings the doorbell before entering another person's home.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
9. Refrains from talking loudly in a public place (for example, in a theater, movie, or church).
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
10. Remains seated during a religious service or a movie.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
11. Asks to eat in a favorite restaurant.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
12. Recognizes and names buildings (for example, hospital, gas station, fire department).
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
13. Identifies neighborhood locations where his or her family obtains needed items (for example, where to buy food).
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
14. Recognizes the need to pay for an item before leaving a store.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
15. Describes the duties of workers (for example, says that firefighters put out fires and doctors help the sick).
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
16. Looks both ways before crossing a street or parking lot.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
17. Asks to go to the library.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
18. Finds the restroom in public places.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
19. Orders own meals when eating out.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
20. Makes a small purchase at a food store.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
21. Carries enough money to make small purchases (for example, a soft drink).
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
22. Walks alone to friends' houses or apartments in the neighborhood.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
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Functional Pre-Academics
Do not complete this skill area if the child being rated is younger than 1 year old. Instructions: Read through this entire packet and indicate if the child that you are rating is able to do the different items that are listed. A 3 indicates that the child can do the task with no issues; a 2 means they need a little help; a 1 means they need a lot of help to do the task, and a 0 means they do not do it by them self at all. Some of the things they may not be able to do yet, indicate that as 0.
1. Points to at least one body part when asked (for example, "head" or "leg").
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
2. Turns book pages one by one.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
3. Points to pictures in books when asked (for example. points to a horse or cow).
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
4. Counts three or more objects.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
5. States his or her age in years when asked.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
6. Sings the alphabet song.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
7. Names six or more colors, including red, blue, and yellow.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
8. Names four or more shapes (for example, circle, square, rectangle, triangle).
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
9. Recites nursery rhymes from memory.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
10. Reads his or her name when printed.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
11. Names at least two letters when shown his or her name.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
12. Identifies at least one coin by name (for example, penny or dime).
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
13. Answers simple questions about a story read to him or her.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
14. Counts 10 or more objects without using fingers.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
15. Draws a recognizable face that includes two eyes, a nose, a mouth, and hair.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
16. Names most letters when shown the alphabet.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
17. Counts from 1 to 20.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
18. Prints at least two letters in his or her name
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
19. Reads and obeys common signs (for example, Do Not Enter, Exit, Stop).
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
20. States the days of the week in order.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
21. Writes or prints his or her first and last name.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
22. Writes numbers 1 through 10 correctly.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
23. Tells which day comes before another (for example, "Wednesday comes before Thursday").
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
24. States days and times of favorite after-school activities, such as sports practice, music lessons, or television shows.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
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Home Living
Do not complete this skill area if the child being rated is younger than 1 year old. Instructions: Read through this entire packet and indicate if the child that you are rating is able to do the different items that are listed. A 3 indicates that the child can do the task with no issues; a 2 means they need a little help; a 1 means they need a lot of help to do the task, and a 0 means they do not do it by them self at all. Some of the things they may not be able to do yet, indicate that as 0.
1. Removes cookies , chips, or other food from a box or bag.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
2. Shows concern when he or she spills something (for example, says "Oh no" or tells an adult).
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
3. Points to where commonly used foods are kept in his or her home (for example, the refrigerator).
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
4. Points to the place where his or her clothes are stored.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
5. Takes a shirt or other piece of clothing out of a drawer when asked.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
6. Assists other people with putting away toys, games, and other items.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
7. Picks up and throws away trash or paper at home.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
8. Does a simple errand when asked (for example, runs to get a towel for a spill).
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
9. Refrains from kicking or hitting furniture.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
10. Turns television on and off.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
11. Refrains from throwing food or paper on the floor.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
12. Washes hands without splashing water on the floor.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
13. Gets own snacks from cabinet or pantry.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
14. Assists adults with preparing simple snacks or meals (for example. hands slices of bread to adult for making sandwiches).
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
15. Places dirty clothes in the proper place (for example, a hamper or clothes basket).
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
16. Wipes up spills at home.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
17. Takes own clothes from drawers or closet when getting dressed.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
18. Keeps dirty shoes and feet off furniture.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
19. Puts his or her own dirty glass or plate in the sink or dishwasher.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
20. Puts things in their proper places when finished using them.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
21. Keeps toys, games, and other belongings neat and clean.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
22. Disposes of his or her leftover food.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
23. Pours liquid from a larger container into own cup or glass without spilling.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
24. Makes his or her bed.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
25. Folds clean clothes.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
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Health and Safety
Instructions: Read through this entire packet and indicate if the child that you are rating is able to do the different items that are listed. A 3 indicates that the child can do the task with no issues; a 2 means they need a little help; a 1 means they need a lot of help to do the task, and a 0 means they do not do it by them self at all. Some of the things they may not be able to do yet, indicate that as 0.
1. Swallows liquid medicines as needed, without fussing.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
2. Sits still in high chair, booster seat, or chair, without climbing or sliding off.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
3. Avoids bumping into walls or objects when crawling or walking.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
4. Allows temperature to be taken without fussing.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
5. Shows, points to, or tells another person about a cut, bruise, or other minor injury
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
6. Follows another person's direction to "stop" when near danger, such as fire or broken glass.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
7. Points to the body part that hurts when he or she is sick or injured.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
8. Remains fairly still when an adult treats a cut or scrape.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
9. Refrains from putting non-edible objects in mouth (for example, crayons, blocks, sand).
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
10. Avoids getting too near a fire, broken glass, or other potential danger.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
11. Avoids touching or playing with dangerous items (for example, insect spray or sharp knives).
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
12. Avoids crawling or climbing on high or dangerous places.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
13. Tells an adult if he or she has a stomachache or other illness.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
14. Tests hot foods before eating them.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
15. Puts on a coat or sweater when cold.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
16. Carries breakable objects safely and carefully.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
17. Asks an adult before going near something that might be dangerous (for example, animals, busy streets, or high playground equipment).
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
18. Buckles own car seat or seat belt.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
19. Carries scissors safely.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
20. Carries hot containers safely and carefully.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
21. Uses electrical outlets or sockets safely.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
22. Cares for own minor injuries (for example, paper cuts, knee scrapes, nosebleeds).
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
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Leisure
Instructions: Read through this entire packet and indicate if the child that you are rating is able to do the different items that are listed. A 3 indicates that the child can do the task with no issues; a 2 means they need a little help; a 1 means they need a lot of help to do the task, and a 0 means they do not do it by them self at all. Some of the things they may not be able to do yet, indicate that as 0.
1. Smiles or shows interest when he or she sees a favorite toy.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
2. Plays with a variety of toys instead of only one or two.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
3. Plays with a single toy or game for at least 1 minute
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
4. Plays alone with toys and games, or does other fun activities.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
5. Plays simple games like "peek-a-boo" or rolls a ball to others.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
6. Looks with an adult at pictures in books or magazines.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
7. Watches for a few minutes as people play with toys or games.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
8. Shows interest in a toy or other object by pointing to it.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
9. Chooses a game or toy during playtime.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
10. Plays with toys, games, or other fun items with others.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
11. Plays with a single toy or game for more than 5 minutes.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
12. Plays on playground equipment.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
13. Asks to be read to from a favorite book.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
14. Attends fun activities at another's home.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
15. Engages in imaginary or make-believe play with others.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
16. Participates regularly in a specific fun activity (for example, listening to a certain type of music or playing a favorite computer game).
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
17. Plays simple games with playmates without adult supervision.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
18. Invites others to join him or her in playing games and other fun activities.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
19. Saves things of interest (for example. rocks. feathers, pictures).
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
20. Waits for his or her turn in games and other fun activities.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
21. Follows the rules in games and other fun activities.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
22. Invites others home for a fun activity.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
23. Plays simple board games.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
24. Participates in an organized program for a sport or hobby (for example, practices basketball or takes a music class).
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
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Self-Care
Instructions: Read through this entire packet and indicate if the child that you are rating is able to do the different items that are listed. A 3 indicates that the child can do the task with no issues; a 2 means they need a little help; a 1 means they need a lot of help to do the task, and a 0 means they do not do it by them self at all. Some of the things they may not be able to do yet, indicate that as 0.
1. Swallows liquids without difficulty.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
2. Sleeps through most of the night, waking no more than one or two times.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
3. Swallows soft, strained, or mashed food such as baby food or applesauce.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
4. Opens mouth when offered food on a spoon.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
5. Feeds himself or herself crackers, cookies, dry cereal, or other finger foods
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
6. Eats firm foods that require biting and chewing (for example, steamed vegetables).
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
7. Drinks from a cup or glass, even if another person must hold it.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
8. Lifts arms as needed when another person is dressing or undressing him 0or her.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
9. Points to or asks for food when hungry.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
10. Takes shoes off.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
11. Feeds himself or herself with a spoon or fork, not hands.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
12. Washes hands with both soap and water.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
13. Wipes his or her own face when given a washcloth by an adult.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
14. Remains dry without wetting throughout the day.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
15. Sits on the toilet or potty seat without being held.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
16. Tells parent or other adult when he or she needs to use the bathroom.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
17. Remains dry without wetting throughout the night.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
18. Brushes teeth with little fussing when told to do so by an adult.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
19. Uses bathroom without help.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
20. Dresses himself or herself.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
21. Buttons own clothing.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
22. Takes a bath or shower without help.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
23. Washes his or her own hair.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
24. Cuts meats or other foods into bite-size pieces with a knife.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
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Self-Direction
Instructions: Read through this entire packet and indicate if the child that you are rating is able to do the different items that are listed. A 3 indicates that the child can do the task with no issues; a 2 means they need a little help; a 1 means they need a lot of help to do the task, and a 0 means they do not do it by them self at all. Some of the things they may not be able to do yet, indicate that as 0.
1. Shows interest in a toy or other object by looking at it for a few seconds.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
2. Sits quietly for at least 1 minute without demanding attention.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
3. Finds something to do for at least 5 minutes without demanding attention.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
4. Plays with a toy without putting it into his or her mouth.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
5. Explores an unfamiliar room or other new situation, even if a parent must encourage it (for example, a doctor's waiting room).
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
6. Chooses the food or snack he or she wishes to eat when given a choice.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
7. Moves a few feet away from a parent in a new situation as long as the parent is in sight (for example, when visiting an unfamiliar residence).
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
8. Tries to do most things alone without an adult's help (for example, dressing or feeding self).
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
9. Follows an adult's request to ''quiet down" or "behave".
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
10. Resists pushing or hitting another child when angry or upset.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
11. Follows simple household rules (for example. "No running in the house").
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
12. Stands still when needed, without fidgeting or moving around.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
13. Starts an activity at once when told to do so (for example, "Go take a bath").
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
14. Controls temper when a parent or other adult takes a toy or object away.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
15. Asks permission from an adult when needed (for example, "May I go outside to play?").
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
16. Keeps working on hard tasks without becoming discouraged, quitting, or needing reminders.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
17. Works independently and asks for help only when necessary.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
18. Stops a fun activity, without complaining, when told that time is up.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
19. Controls temper when disagreeing with friends.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
20. Follows a routine without being reminded (for example, brushing teeth before bedtime or feeding a pet).
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
21. Asks permission before playing with another child's toy or game.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
22. Chooses own clothes almost every day.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
23. Works on one home or school activity for at least 15 minutes without reminders.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
24. Discusses ways to solve conflicts with others (for example. "You can have this now if I can have it later").
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
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Social
Instructions: Read through this entire packet and indicate if the child that you are rating is able to do the different items that are listed. A 3 indicates that the child can do the task with no issues; a 2 means they need a little help; a 1 means they need a lot of help to do the task, and a 0 means they do not do it by them self at all. Some of the things they may not be able to do yet, indicate that as 0.
1. Smiles when he or she sees a parent.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
2. Relaxes body when held(for example, snuggles).
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
3. Squeals or laughs when happy or delighted.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
4. Displays closeness to a parent (for example, is happy when parent returns).
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
5. Shows a sense of humor (for example, laughs when someone acts silly).
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
6. Lifts arms to express a desire to be picked up.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
7. Responds differently to familiar and unfamiliar persons (for example, is less warm to an unfamiliar person).
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
8. Hugs and kisses parents or others.
*
0 Is not able
1 Never (or almost never)
1 Sometimes when needed
3 Always (or almost always)
9. Imitates actions of adults (for example, pretends to clean house or drive a car).
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
10. Shows respect for persons in authority by following their rules and directions (for example, parents, teachers, police officers).
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
11. Shares toys willingly with others.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
12. Greets other children (for example, says "Hi").
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
13. Says "Thank you" when given a gift.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
14. Shows sympathy for others when they are sad or upset.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
15. Seeks friendship with others in his or her age group.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
16. Responds appropriately when introduced to others (for example, says "Hello").
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
17. Says "Please" when asking for something.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
18. Says when he or she feels happy, sad, scared, or angry.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
19. Displays good table manners (for example, by using a napkin and remaining at the table until excused).
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
20. Offers assistance to others (for example, to carry packages or put away food).
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
21. Apologizes if he or she hurts the feelings of others.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
22. Places reasonable demands on friends (for example. does not become upset when a friend plays with another friend).
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
23. Refrains from saying or doing things that might embarrass or hurt others.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
24. Personally makes or buys gifts for family members on birthdays or major holidays.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
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Motor
Instructions: Read through this entire packet and indicate if the child that you are rating is able to do the different items that are listed. A 3 indicates that the child can do the task with no issues; a 2 means they need a little help; a 1 means they need a lot of help to do the task, and a 0 means they do not do it by them self at all. Some of the things they may not be able to do yet, indicate that as 0.
Lifts head to look around.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
2. Follows a moving object by turning head.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
3. Rolls from stomach to side.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
4. Shakes rattle or other toys.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
5. Reaches for objects such as a bottle or toy.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
6. Transfers objects from one hand to the other.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
7. Sits upright on the floor without support.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
8. Moves to a sitting position, even if balance is unsteady.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
9. Pulls himself or herself to a standing position (for example, in a crib).
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
10. Picks up small flat objects from a table (for example, coins or buttons).
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
11. Crawls for about 10 feet without falling over.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
12. When standing, bends over to pick up items from the floor.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
13. Stands up from a sitting position.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
14. Rolls ball to others.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
15. Walks without help.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
16. Throws a small ball overhand.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
17. Walks up at least five to six steps without falling (may use handrail).
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
18. Kicks a ball without falling.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
19. Runs without falling.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
20. Bounces a ball for several seconds.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
21. Catches a ball tossed from 5 to 10 feet away.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
22 . Draws straight lines across a piece of paper.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
23. Colors within the lines of a drawing or in a coloring book.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
24. Puts twist-off tops back on jars and closes them tightly.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
25. Uses scissors to cut along a straight line.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
26. Uses scissors to cut shapes with curved lines.
*
0 Is not able
1 Never (or almost never)
2 Sometimes when needed
3 Always (or almost always)
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