Self-help and Social-Emotional Scales

Teacher Report and Scoring Form—Self-help and Social-Emotional ScalesYear Month DayDate ofChild’s Name ___________________________________________________ Screening ______ ______ ______ School/Program __________________________________Parent(s)/Caregiver(s) ____________________________________________ Birth Date ______ ______ ______ Teacher _________________________________________Directions: Read each item and circle the response or description that best reflects the child’s behavior or skill level.Age ______ ______ ______ Examiner ________________________________________A. Eating SkillsSELF-HELP SKILLS1. Does ______ use a spoon?If yes, does ______ place the spoon in his/her mouth withoutturning the spoon upside down, with little or no spilling of food?Rarely/No = 0 Sometimes = 0 Most of the time = 12. Does ______ use the side of the fork for cutting soft food,such as a piece of baked potato or a piece of cake?Rarely/No = 0 Sometimes = 0 Most of the time = 13. Does ______ hold a fork in his/her fingers, not in his/her fist?B. Dressing SkillsRarely/No = 0 Sometimes = 0 Most of the time = 1____ / 1____ / 1____ / 1Total for A. Eating Skills ____ /34. Does ______ put on his/her shoes?Criteria: Buckling, tying, or Velcro ® fastening is not requiredfor credit.No = 0Yes (sometimes onwrong feet) = 15. Does ______ dress himself/herself unsupervised?Rarely/No = 0 Sometimes = 0Yes (completely dresses himself/herself,putting all clothes on correctly andfastening all fasteners) = 26. Does ______ put on his/her socks?Yes (each shoe oncorrect foot 90%of the time) = 2Most of the time, exceptfor help with difficultfasteners = 1Yes (completely dresses himself/herself,including tying shoelaces and fasteningall fasteners) = 3Rarely/No = 0 Sometimes = 0 Most of the time = 1____ / 2____ / 3____ / 1Total for B. Dressing Skills ____ /678 BRIGANCE ® Early Childhood Screen III (K & 1) ©Curriculum Associates, LLCC. Toileting Skills7. Does ______ get on the toilet or potty by himself/herself(even if he/she needs help with clothing)?Rarely/No = 0 Sometimes = 0 Most of the time = 18. Does ______ have bowel movements (“poop”) in the toiletor potty (no more than one accident a week)?Rarely/No = 0 Sometimes = 0 Most of the time = 19. Does ______ urinate (“pee”) in the toilet or potty (no morethan one accident a week)?Rarely/No = 0 Sometimes = 0 Most of the time = 110. Does ______ attempt to wipe himself/herself after toileting?ORRarely/No = 0 Sometimes = 0 Most of the time = 1(Answer only the more appropriate of these two questions.)Does ______ wipe himself/herself independently aftertoileting?Rarely/No = 0 Sometimes = 0 Most of the time = 211. Does ______ take care of his/her toileting needs?Rarely/No = 0 Sometimes = 0Yes (flushing thetoilet most ofthe time afterusing it) = 1Yes (flushing thetoilet and washingand drying his/herhands most of thetime) = 212. Does ______ go to the bathroom on his/her own without beingasked or reminded?Rarely/No = 0 Sometimes = 0 Most of the time = 1____ / 1____ / 1____ / 1____ / 2____ / 2____ / 1Total for C. Toileting Skills ____ / 8TOTAL FOR SELF-HELP(A. Eating Skills, B. Dressing Skills, C. Toileting Skills) ____ / 17Teacher Report and Scoring Form—Self-help and Social-Emotional ScalesSelf-help and Social-Emotional Scales

Teacher Report and Scoring Form—Self-help and Social-Emotional Scales (continued)SOCIAL AND EMOTIONAL SKILLSD. Relationships with Adults13. Does ______ respond with feelings of pride and enthusiasmwhen he/she earns positive feedback?Rarely/No = 0 Sometimes = 0 Most of the time = 114. Does ______ look forward to sharing his/her feelings with youwhen he/she is happy?Rarely/No = 0 Sometimes = 0 Most of the time = 115. Does ______ enjoy sharing information with you about himself/herself, such as things he/she likes, names of his/her familymembers or pets, or what he/she did over the weekend?Rarely/No = 0 Sometimes = 0 Most of the time = 116. Does ______ share his/her thoughts and ideas with you?Rarely/No = 0 Sometimes = 0 Most of the time = 1____ / 1____ / 1____ / 1____ / 1Total for D. Relationships with Adults ____ / 4E. Play and Relationships with Peers17. Does ______ have several friends but one who is a special orbest friend?No = 0 Yes = 118. Does ______ have a best friend with whom he/she is close andwho reciprocates by coming over for play dates or extendingan invitation to a party?No = 0 Yes = 119. Does ______ play cooperatively in a large-group game, such asduck-duck-goose, tag, or kickball?Rarely/No = 0 Sometimes = 0 Most of the time = 120. Does ______ give verbal directions or incorporate verbaldirections into play activities?Rarely/No = 0 Sometimes = 0 Most of the time = 1____ / 1____ / 1____ / 1____ / 1Total for E. Play and Relationships with Peers ____ / 4F. Motivation and Self-Confidence21. Does ______ maintain interest when engaged in a small-groupactivity or project?Rarely/No = 0 Sometimes = 0 Most of the time = 122. Does ______ show that he/she likes to finish what he/she starts,perhaps by dawdling less than at an earlier age?Rarely/No = 0 Sometimes = 0 Most of the time = 123. Does ______ approach new tasks with confidence and a“can-do” attitude?Rarely/No = 0 Sometimes = 0 Most of the time = 124. Does ______ remain focused on what he/she has been askedto do even when there are minor distractions, such as a carmaking noise outside or someone tapping a pencil?Rarely/No = 0 Sometimes = 0 Most of the time = 179 BRIGANCE ® Early Childhood Screen III (K & 1) ©Curriculum Associates, LLC Teacher Report and Scoring Form—Self-help and Social-Emotional Scales____ / 1____ / 1____ / 1____ / 1Total for F. Motivation and Self-Confidence ____ / 4G. Prosocial Skills and Behaviors25. If supervised by an adult, does ______ take turns withoutundue objection?Rarely/No = 0 Sometimes = 0 Most of the time = 126. Does ______ understand or accept the need to share and taketurns, perhaps willingly taking turns even if he/she isn’t asked to?Rarely/No = 0 Sometimes = 0 Most of the time = 127. Does ______ ask an adult for permission before using things thatbelong to others or before engaging in an activity that may berestricted, such as going to the bathroom or leaving the classroom?Rarely/No = 0 Sometimes = 0 Most of the time = 128. Does ______ react to a disappointment or failure in anacceptable manner by being a good sport and refraining fromshouting or getting upset?Rarely/No = 0 Sometimes = 0 Most of the time = 1____ / 1____ / 1____ / 1____ / 1Total for G. Prosocial Skills and Behaviors ____ / 4TOTAL FOR SOCIAL-EMOTIONAL(D. Relationships with Adults, E. Play and Relationships with Peers,F. Motivation and Self-Confidence, and G. Prosocial Skills and Behaviors) ____ / 16Self-help and Social-Emotional Scales