Child's Name
Parent's Name
School
Teacher
Examiner
Child's Date of Birth*
Date Tested*
*Required
Self-help
A. Total for Work/Help Skills (1-7) / 13
B. Total for Feeding/Eating Skills (8-10) / 4
C. Total for Undressing/Dressing Skills (11-16) / 9
D. Total for Toileting Skills (17-22) / 7
Teacher's Evaluation (23) / 2
Social-Emotional
E. Total of Play Skills and Behaviors (24-28) / 12
F. Total for Gets Along with Others (29-33) / 5
Teacher's Evaluation (34) / 2
Teacher's Evaluation (35) / 2