Sensory Assessment - Teacher
Teacher Questionnaire
Student's name:
Date of birth:
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Month
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Day
Year
Date
Age:
Gender:
School:
Grade:
Respondent(s):
Relationship to student:
Date completed:
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Month
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Day
Year
Date
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Instructions
This questionnaire is designed to help gather information from the teacher(s) of the student being evaluated. Please provide detailed descriptions and examples for each question. Information provided is confidential and should not be shared with anyone except the professional conducting this evaluation.
Concerns
Describe your major concerns about this student at the present time.
Organizational skills
Describe this student's organizational skills.
Is this student able to manage their class materials independently?
What assistance is the student currently receiving in this area?
Relationships - peers
Describe this student's social relationships with peers.
Does this student seek out peers during free time? Describe what you have noticed about this student's social interactions with his/her peers during free time.
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Does this student display any difficulty interpreting social cues, such as humor or joking?
Does this student adopt a role of correcting the behavior of his/her peers?
Does this student routinely report on the actions of their peers to the adult in charge?
Is this student able to work cooperatively in small groups?
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Relationships - adults
Describe this student's relationships with adults.
Does this student seek out adult over peer interactions? Is the student more comfortable talking to adults than peers?
Does this student recognize the hierarchy role of the teacher, or do they act in a way that shows a lack of awareness of the different roles of teachers and students?
Communication style
Describe the student's communication style.
Are this student's comments in class generally relevant to the topic being discussed?
Does the student speak in a formal or scripted way or in a way that seems unusual in comparison with their peers?
Does this student prefer telling detailed information or facts in a one-sided way, or can they maintain a back-and-forth conversation?
Preoccupations/skills/interests
What eccentric preoccupations, highly developed skills, or areas of intense interest and focus does this student display?
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Sensory behaviors
Does the student display sensory differences in any of the following areas:
Tactile
Does this student frequently touch or hold objects?
Does this student pick at their skin or hair, or place his/her fingers, hair, or other objects into their mouth?
Visual details
Does the student seem to notice or comment on visual details that others do not pay attention to? Can you give an example?
How does this student react to changes in visual details, for example, if something is moved or rearranged on their desk or in the classroom?
Noises
What types of noises bother this student? How do they react?
What types of noises does this student seek out?
Smells
Are there particular smells that this student dislikes or comments on as being bothersome?
Does this student ever explore objects by smelling them?
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Body boundaries
Does this student become upset when they perceive others to be standing too close and entering their personal space?
Does this student show a lack of awareness of personal space by standing too close and entering the personal space of others?
Does this student need frequent reminders to keep their hands, feet, or body out of the personal space of others?
Crowded places
How does this student react in crowded places?
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Transition times and changes in routine
How does this student react during transition times?
How difficult is it for this student to transition away from a preferred activity to an activity you are directing the student to do?
Is this student able to follow the flow of the daily routine without additional prompts?
If additional prompts are required, what strategies have worked well with this student?
How does this student react to changes in routines?
Does this student do better when you prepare them for changes in advance?
Do you ever prepare the student for a change in routine by presenting it in a written or visual format, such as a calendar or list?
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Physical movements
Is the student generally clumsy?
Does the student walk in an odd manner in the hallway?
Is sitting during instruction time difficult for this student?
Is physical education class a source of stress for him/her?
Academic abilities
Describe this student's academic abilities.
What are their areas of greatest strength and ability?
What are their areas of greatest challenge?
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Discuss any frustrations or difficulties this student displays in the area of handwriting.
Describe this student's skills in the area of written assignments.
Behavior during unstructured times
Describe this student's behavior during unstructured times, such as in the hallway, at lunch, at recess, or during passing periods.
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Emotional qualities
Discuss this student's emotional qualities. Does this student seem to display a high anxiety level? In what way?
What specific situations seem to trigger anxiety?
Does this student act like a younger child? In what way?
Describe how this student manages frustration.
What situations trigger anger or agitation?
How does this student express anger or agitation?
What helps this student to calm down when angered or agitated?
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Three words/qualities to describe student
What three words or qualities would best describe this student?
Closing questions
Is there anything else you would like us to know about this student?
What do you hope to gain from this evaluation?
Do you have any specific questions about the evaluation process?
Additional notes
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