1. ASSESSMENT CHECKLIST FOR CHILDREN WITH
DISABILITY
Date of Assessment:_______________________
Name: _______________________________________________________
Date of Birth: ________________________ Age: _______ Sex: _______
I. Cognitive Behavior OK NEEDS REVIEW
1. Performance Observation
Pencil is held properly ( ) ( )
Paper is positioned at a ‘normal’ slant ( ) ( )
Writing posture is acceptable ( ) ( )
Writing speed is acceptable ( ) ( )
2. Correct Letter Formation
Closed letters are closed ( ) ( )
Looped letters are looped ( ) ( )
Stick letters are not looped ( ) ( )
i’s and j’s are dotted directly above ( ) ( )
x’s and t’s are crossed accurately ( ) ( )
m’s and n’s have the correct number of bumps ( ) ( )
All lowercase letters begin on the line (unless ( ) ( )
they follow b. o, v or w)
All lowercase letters end on the line ( ) ( )
v’s and u’s are clearly not ry and ry ( ) ( )
Uppercase letters are correctly or acceptably ( ) ( )
formed
Numbers are correctly formed ( ) ( )
3. Fluency
Writing is smooth not choppy ( ) ( )
Pencil pressure appears even ( ) ( )
Words appear to be written as complete units ( ) ( )
2. 4. Reading YES NO
Loses place in a line while reading ( ) ( )
Repeats, omits or add words ( ) ( )
Does not read fluently ( ) ( )
Confuses similar words or letter as to ( ) ( )
visual configuration
Uses fingers to follow the line while reading ( ) ( )
Dislikes reading ( ) ( )
Shows indication of proof reading skills, but ( ) ( )
not necessarily in all areas
Has difficulty understanding or remembering ( ) ( )
what is read to him
Has difficulty remembering the sequence of ( ) ( )
events of a story read
5. Mathematics
Has difficulty associating numbers with symbol ( ) ( )
Cannot recall Math facts instantly ( ) ( )
Shows confusion with columns and spacing ( ) ( )
Has difficulty with story problems ( ) ( )
Fails to comprehend Math concepts ( ) ( )
Has difficulty in the formation of geometric ( ) ( )
shapes and numbers
Makes reversals of numbers in writing and/or ( ) ( )
reading after sufficient instruction and practice
Demonstrates confusion with written and/or ( ) ( )
oral arithmetic
6. Hearing/Speech
Shows indications of delayed speech ( ) ( )
Has trouble/difficulty following oral directions ( ) ( )
Does not often seem to listen when spoken to ( ) ( )
Has a poor listening skill ( ) ( )
Has an articulation problem ( ) ( )
II. Motor Behavior
Shows clumsy movements on the playground ( ) ( )
and/or in classroom; for example, constantly
tripping over chairs, running into play
equipment, etc
Have difficulty hopping, skipping, jumping, ( ) ( )
walking and climbing stairs, which may indicate
immature physical development
Has difficulty walking in straight lines ( ) ( )
and/or balance beams
Has difficulty buttoning, zippering and ( ) ( )
snapping articles of clothing
3. Cannot easily cut with scissors ( ) ( )
Holds crayons and pencil awkwardly ( ) ( )
Demonstrates confusion with direction ( ) ( )
of left, right, up down, in front, behind, etc.
III. Social Behaviors
Demonstrate confusion when changes are ( ) ( )
made in any daily routine
Usually sloppy ( ) ( )
Demonstrates destructive behavior ( ) ( )
over belongings
Tends to be easily distracted by visual or ( ) ( )
auditory stimuli
Maybe demanding or attracts individual ( ) ( )
attention through overt behavior tactics,
for example, loudly interrupting teacher or
others in the middle of class activities
Has difficulty in getting along with peers ( ) ( )
and/or adults
May show indications of certain physical ( ) ( )
characteristics such as nervousness, startled
movements, uneasiness when sitting for
even a short period of time, etc
May pout or cry easily with easily with very ( ) ( )
little season
May exhibit flighty or erratic behavior such as ( ) ( )
getting up in the middle of a work period to
dance around
May tell tales or bizarre stories to peers and/or ( ) ( )
teacher
Has an unusually short attention span for ( ) ( )
his/her age
Prepared by:
___________________________________________________________
