Executive Skills Questionnaire for Children (Grades 4-5)

Name

First NameLast Name

Email

example@example.com

Date

1) Handles conflict with peer without getting into physical fight (may lose temper).

2) Follows home or school rules in the absence of an adult's immediate presence.

3) Can calm down or de-escalate quickly from an emotionally charged situation when prompted by an adult.

4) Remembers to follow a routine chore after school without reminders.

5) Brings books, papers, assignments to and from school.

6) Keeps track of changing daily schedule (e.g., different activities after school).

7) Doesn't overreact to losing a game or not being selected for an award.

8) Can accept not getting what he/she wants when working/playing in a group.

9) Acts with restraint in response to teasing.

10) Can spend 30-60 minutes on homework assignments.

11) Can complete a chore that takes 30-60 minutes (may need a break).

12) Is able to attend sports practice, church service, etc. for 60-90 minutes.

13) Is able to follow a three- to four-step routine that has been practiced.

14) Can complete three to four classroom assignments in a row.

15) Can follow established homework schedule (may need reminder to get started).

16) Can make plans to do something special with a friend (e.g., go to the movies).

17) Can figure out how to earn/save money for a more expensive purchase.

18) Can carry out long-term project for school, with most steps broken down by someone else.

19) Can put belongings in appropriate places in bedroom or other locations.

20) Brings in toys from outdoors after use or at end of day (may need reminder).

21) Keeps track of homework materials and assignments.

22) Can complete daily routines within reasonable time limits without assistance.

23) Can adjust homework schedule to allow for other activities (e.g., starting early if there's an evening Scout meeting).

24) Is able to start long-term projects enough in advance to reduce time crunch (may need help with this).

25) Can save allowance for 3-4 weeks to make desired purchase.

26) Is able to follow a practice schedule to get better at a desired skill (sport, instrument) - may need reminders.

27) Can maintain a hobby over several months.

28) Doesn't "get stuck" on things (e.g., disappointments, slights).

29) Can "shift gears" when plans have to change due to unforeseen circumstances.

30) Can do "open-ended" homework assignments (may need assistance).

31) Is able to anticipate in advance the result of a course of action and make adjustments accordingly (e.g., to avoid getting in trouble).

32) Can articulate several solutions to problems and explain the best one.

33) Enjoys the problem-solving component of school assignment or video games.

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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