Executive Skills Questionnaire for Children (Grades 1-3)

Name

First NameLast Name

Email

example@example.com

Date

1) Can follow simple classroom rules.

2) Can be in close proximity to another child without need for physical contact.

3) Can wait until parent gets off phone before telling him/her something (may need 1 reminder).

4) Is able to run errand with two to three steps.

5) Remembers instructions given a couple of minutes earlier.

6) Follows two steps of a routine with one prompt.

7) Can tolerate criticism from an adult.

8) Can deal with perceived "unfairness" without undue upset.

9) Is able to adjust behavior quickly in new situation (e.g., calming down after recess).

10) Can spend 20-30 minutes on homework assignments.

11) Can complete a chore that takes 15-20 minutes.

12) Can sit through a meal of normal duration.

13) Can remember and follow simple one- to two-step routines (such as brushing teeth and combing hair after breakfast).

14) Can get right to work on classroom assignment following teacher instruction to begin.

15) Will start homework at established time (with one reminder).

16) Can carry out a two- to three-step project of own design (e.g., arts and crafts, construction).

17) Can figure out how to earn/save money for an expensive toy.

18) Can carry out two- to three-step homework assignment with support (e.g., book report).

19) Puts coat, winter gear, sports equipment in proper locations (may need reminder).

20) Has specific places in bedroom for belongings.

21) Doesn't lose permission slips, notices from school.

22) Can complete a short task within time limits set by an adult.

23) Can build in appropriate amount of time to complete a chore before a deadline (may need assistance).

24) Can complete a morning routine within time limits (may need practice).

25) Will stick with challenging task to achieve desired goal (e.g., building difficult Lego construct).

26) Will come back to task later if interrupted.

27) Will work on desired project for several hours or over several days.

28) Plays well with others (doesn't need to be in charge, can share, etc.).

29) Tolerates redirection by teacher when not following instructions.

30) Adjusts easily to unplanned-for situations (e.g., substitute teacher).

31) Can adjust behavior in response to feedback from parent or teacher.

32) Can watch what happens to others and change behavior accordingly.

33) Can verbalize more than one solution to a problem and make the best choice.

Calculation

1-3 Response Inhibition

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4-6 Working Memory

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7-9 Emotional Control

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10-12 Sustained Attention

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13-15 Task Initiation

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16-18 Planning/Prioritization

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19-21 Organization

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22-24 Time Management

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25-27 Goal-Directed Persistence

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28-30 Flexibility

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31-33 Metacognition