PROBLEM CHECKLIST

 TEACHER’S REPORT FORM

TODAY’S DATE:

Month __ Date __ Year __

CHILD’S FULL NAME:

First                       Middle                 Last
____________________________________

CHILD’S GENDER              CHILD’S AGE             CHILD’S ETHNIC GROUP

  __Boy     __Girl                __________                 ___________________

CHILD’S BIRTHDAY:

Month ____ Date ____ Year ____ 

Please fill out this form to know your perspective on child’s behavior. Please fill this out completely and you are free to write additional comment beside the space provided.
Name and address of the School:___________________________________________ 

I. What kind of a facility is it?  (Please be specific, e.g., home day care, day care center, nursery school, preschool, school readinessclass, Early Childhood Special Education, Headstart, Kindergarten, etc.)

_________________________________________________________________
II. What is the average number of children in the class?  __________________

III. How many hours the child spend in the school per week? ______________

IV. For how many months have you known the child? ___________________

V.  How well do you know him/her?   

 __A.Not well   __B.Moderately well   __C.Very well

VI. Has he/she ever been referred for a special education program or special services?

          __I Don’t Know            __No           __Yes – what kind ?­­­­­­­­­­­­­­­­­­­­­­­­­­­­­

Below is a list of items that describe children. Circle the 1 if the item is somewhat or sometimes true of the child. If the item is not true of the child, circle the 0. Please answer all items as well as you can, even if some do not seem to apply to the child.

0 = Not True (as far as you know) 1 = Somewhat or Sometimes True 2 = Very True or Often True­­­­­­­­­­­­­­­­­­­

1  2  3     1. Acts too young for age

1  2  3     2. Afraid to try new things

1  2  3     3. Avoids looking others in the eye

1  2  3     4. Chews on things that aren’t edible

1  2  3     5. Clings to adults or too dependent

1  2  3     6. Constantly seeks help

1  2  3     7. Apathetic or unmotivated

1  2  3     8. Cries a lot

1  2  3     9. Demands must be met immediately

1  2  3     10. Destroys his/her own things

1  2  3     11. Destroys property belonging to others

1  2  3     12. Daydreams or gets lost in his/her thoughts

1  2  3     13. Disobedient

1  2  3     14. Disturbed by any change in routine

1  2  3     15. Can’t stand waiting; wants everything now

1  2  3     16. Cruelty, bullying, or meanness to others

1  2  3     17. Doesn’t answer when people talk to him/her

1  2  3     18. Doesn’t get along with other children

1  2  3     19. Doesn’t know how to have fun; acts like alittle adult 

1  2  3     20. Disturbs other children

1  2  3     21. Easily frustrated

1  2  3     22. Easily jealous

1  2  3     23. Feelings are easily hurt

1  2  3     24. Gets hurt a lot, accident-prone

1  2  3     25. Gets in many fights

1  2  3     26. Gets into everything

1  2  3     27. Gets too upset when separated from parents

1  2  3     28. Hit and kick his classmate

1  2  3     29. Eats or drinks things that are not food—do notinclude sweets (describe):______________________________________________

1  2  3     30. Fears certain animals, situations, or placesother than daycare or school

(describe):______________________________________________

Fill out this following question.

·          Does the child have any illness or disability (either physical or mental)?

__No      __Yes—Please describe:

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

·          What concerns you most about the child?

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

·          Please describe the best things about the child:

     __________________________________________________________________

     __________________________________________________________________

     __________________________________________________________________