PRESCHOOL / CRÈCHE TEACHER QUESTIONNAIRE
Section 1: General Information
1. Name of Child
First Name
Last Name
2. Date of Birth
-
Month
-
Day
Year
Date
3. Setting Name and Address
4. Room name/ Class Group
5. Your Name
First Name
Last Name
6. Your Role
7. How long have you known the child / how often do you work with them?
Section 2: Developmental Overview
8. In your view, is the child’s overall development:
Age appropriate
Slightly delayed
Significantly delayed
Advanced
9. Please comment on areas of strength or differences
Section 3: Communication and Language
10. How does the child communicate?
Uses spoken language
Uses gestures or pointing:
Uses nonverbal cues (e.g., pulling adult’s hand):
Uses alternative methods (e.g., PECS, signs, AAC)
11. Does the child respond to their name
Consistently
Sometimes
Rarely
Never
12. Does the child follow simple instructions?
Yes
No
13. Does the child initiate interaction with others?
Yes
No
14. Does the child use eye contact in interactions?
Yes
No
15. Any concerns about speech clarity, vocabulary, or language development?
Section 4: Social Development and Play
16. How does the child engage with peers?
17. What type of play does the child most enjoy?
Seeks out peers
Prefers to play alone
Plays alongside but not with others
Plays cooperatively
Shows limited interest in peers
18. How does the child interact with staff?
19. What type of play does the child most enjoy?
Pretend play
Sensory play
Construction
Outdoor/ movement play
Repetitive play
Watching others
Exploring objecs
20. Does the child:
Use pretend/ imaginative play?
Engage in repetitive play or fixates on particular toys/ topics?
Struggles to transition between activities?
21. Any other information regarding play:
Section 5: Behaviour and Regulation
22. How does the child typically express emotions (e.g., happiness, frustration)?
23. Are there behaviours of concern?
Tantrums/ meltdowns
Aggression
Withdrawal
Self Injury
High Activity Level
Risk taking
Rigid Routines
Sensory Seeking Behaviours
24. Please describe situations or triggers:
25. How does the child respond to changes in routine or new situations?
26. Does the child require support to calm or regulate? If so, what strategies are helpful?
Section 6: Sensory and Physical Profile
27. Are there any sensory concerns noted?
Overreacts to noise
Avoids certain textures
Seeks movement/input
Mouths or smells objects
Sensitive to light/touch/smells
28. Are there concerns about:
Gross Motor skills (e.g., climbing, balance, jumping)?
Fine Motor Skills (e.g., using crayons, puzzles, feeding)?
29. Toilet training progress?
Age-typical
Delayed
Fully trained
Not yet
Section 7: Attendance, Participation & Support
30. Does the child attend regularly?
Yes
No
If no, please specify reason for absence?
31. Has the child been referred for or received support from:
Early Intervention/ CDNT
Speech and Language Therapy
Psychology
Other (please specify)
32. What strategies or accommodations are in place to support the child in your setting?
33. Is Aims Support in Place? (specify level)
Section 8: Additional Comments
34. Are there any other observations, strengths, or concerns you would like to share?
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: