This document contains an assessment checklist for children with disabilities. It evaluates cognitive behavior, motor skills, and social behaviors. The checklist contains over 50 criteria across these categories to assess letter formation, reading, math, speech, physical coordination, social skills, attention span, and other areas as potential needs for a child named in the document. The child's date of birth, age, sex and the date of assessment are provided at the top.

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:
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