Yes No In what way Does the child get confused about following instructions for

Yes no in what way does the child get confused about

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Yes No In what way? _________________________ Does the child get confused about following instructions, for example when playing a game? 11. Is he learning to distinguish right from wrong? Yes No Is he beginning to develop conscience and sense of morality? Yes No 12. Is he achieving personal independence? Yes No Is he able to finish task on hand? Yes No Able to follow? Yes No 13. Is there any obsessive, compulsive or unusual behavior that the child shows? Yes No Please describe it? ______________________________________________________________________ ASSESSMENT GIVEN
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1. Has the child been evaluated/screened/assessed? _________________________________________________ When/Where? ______________________________________________________________________________ By whom? ______________________________________________________________________________ __ What specific assessment tool/s? _______________________________________________________________ 2. Was there been recommendations for the child? ____________________________________________________ What type of program or activities was recommended? _____________________________________________ Is it properly implemented? ___________________________________________________________________ By whom? ________________________________________________________________________________ 3. Did the child undergo to the recommendation or intervention? __________________________________________ For how long? _______________________________________________________________________________ 4. Was there a review of the intervention program? ___________________________________________________ By whom? _________________________________________________________________________________ 5. Has the child been re-assessed after given an intervention? ___________________________________________ Exclusively for SPED 1005/2005 Students Batch 2008 Basic Information Checklist Interview Edition-Survey Form Prepared by Marlyn C. Saludes, MAED-SPED Visiting Professor Graduate School of Holy Cross of Davao College October 24, 2008
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Checklist on Learning and Behavior Characteristics (CLBC) Name of the Child: _________________________________________________________ Birthday: ______________________________________________Age: _______________ Grade level: ________________________________Date Observed:______________________ Current classification: _______________________________________________________ Educational Placement/Program: _____________________________________________ Observer:_________________________________________ Directions: You will be asked to evaluate the child objectively based on your observation and interactions with him/her. The child will be rated each item by checking under the column. Characteristics Sometimes (1 point) Most Of The Time (2 Points) All Of The Time (3 Points) I. LEARNING ABILITY A. Spelling 1. Uses incorrect letter order 2. Cannot spell correctly at grade level 3. Cannot write from dictation at grade level 4. Reverse letters or entire words B. Writing 1. Cannot write name or other information 2. Cannot stay on line 3. Cannot copy simple sentences from the board 4. Cannot write simple sentences from dictation 5. Cannot do regular work in writing for grade level C. Reading 1. Does not like to read 2. Loses place when reading 3. Repeat, omits or adds words 4. Cannot read the DOLCH Sight Words for grade level 5. Uses fingers to follow a line 6. Cannot understand/remember what he/she reads D. Mathematics 1. Has difficulty associating numbers with symbol 2. Reverse two-place numbers (e.g. 13 for 31 or vice versa) 3. Cannot recall math facts at grade level 4. Fails to comprehend math concepts 5. Gets confused with written and/or oral arithmetic 6. Cannot identify shapes, sizes and colors of objects E. Hearing/Speech 1. Does not seem to listen when spoken to
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2. Cannot follow oral direction 3. Has articulation problems; wrong pronunciation of words; speech not clear 4. Has infantile (baby) speech F. Psychomotor 1. Displays poor motor coordination in using scissors, crayons, pencil, etc.
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