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  2. 2014
  3. July
  4. P
  5. Parent Feedback Form (3-8) 080414
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Questions marked with an * are required Exit Survey
 
 
* Child's First Name : 
* Child's Last Name : 
 
 
 
* Child's date of birth
 
 
 
* Child's Age
 
 
 
* Child's Grade in School
 
 
Section 3-8 SP
Please check the box that most accurately describes your child's ability to perform each task:
Activity Not Expected Child Needs Help All/Most of the Time Child Needs Help 50% of the Time Child Needs Help Occasionally Child Performs Task Without Help
1. Holds and uses pencil, utensils, simple tools with fingers instead of fist
2. Matches and sorts by color, size, shape
3. Uses scissors for snipping or continuous cuts
4. Can cut out recognizable forms to 1/2" of the outline
5. Can copy simple patterns of 4+ parts: beads, blocks, pegs, connecting toys
6. Uses both hands at the same time to work on different tasks (for example, holds paper while drawing)
7. Counts objects accurately
8. Makes simple drawings that are recognizable
9. Knows upper and lower case letters by sight
10. Prints own name in uppercase/lowercase combination
Activity Not Expected Child Needs Help All/Most of the Time Child Needs Help 50% of the Time Child Needs Help Occasionally Child Performs Task Without Help
11. Prints numbers and letters without copying, but by request
12. Prints simple 3-4 letter words, without copying
13. Can reason through simple problems
14. Attempts to solve problems
15. Can type single letters on a keyboard or iPad
16. Plans time to meet need
17. Follows a school schedule with transitions
 
 
Section 3-8 WS
Please check the box that most accurately describes your child's ability to perform each task:
Activity Not Expected Child Needs Help All/Most of the Time Child Needs Help 50% of the Time Child Needs Help Occasionally Child Performs Task Without Help
1. Identifies details in the environment with accuracy
2. Distinguishes objects by size, amount, category
3. Can move around obstacles during games/play
4. Can name simple objects by descriptions or clues only
5. Able to lock/unlock a door using a key
6. Has developed a dominant hand for work
7. Uses two hands in a coordinated manner
8. Can push/pull with arms and hands while using tools
9. Manipulates tiny objects with fingers without dropping
10. Participates at parties and events
11. Completes 2-3 step jobs/errands that take less than one hour.
12. Can tidy/clean independently
13. Displays interactive trading and sharing
14. Appropriate social behavior outside of family
15. Contributes to social interactions with family and familiar others
 
 
Section 3-8 SPL
Please check the box that most accurately describes your child's ability to perform each task:
Activity Not Expected Child Needs Help All/Most of the Time Child Needs Help 50% of the Time Child Needs Help Occasionally Child Performs Task Without Help
1. Walks on tiptoes 10 feet with balance
2. Can hop, skip, or jump forward and backward
3. Can walk or run forward and backward
4. Can pedal a riding toy, trike, or scooter
5. Can toss a tennis ball at least 10 feet at a target
6. Can catch a small-medium size ball from 10 feet
7. Sways, claps in rhythm, dances, and moves to music
8. Balances on a 4” balance beam or line
9. Play is based upon real life scenarios, not fantasy
10. Participates in organized games or sports with rules
Activity Not Expected Child Needs Help All/Most of the Time Child Needs Help 50% of the Time Child Needs Help Occasionally Child Performs Task Without Help
11. Plays with friends cooperatively
12. Uses appropriate speed on swings and riding toys
13. Respects personal space
14. Balances school and leisure interests
15. Can form recognizable objects out of clay or dough
16. Able to perform crafting/building projects
17. Pumps and maintains momentum on a swing
18. Connects 5+ interlocking puzzle pieces with familiar pictures
 
 
Section 3-8 SC
Please check the box that most accurately describes your child's ability to perform each task:
Activity Not Expected Child Needs Help All/Most of the Time Child Needs Help 50% of the Time Child Needs Help Occasionally Child Performs Task Without Help
1. Undresses with help for fasteners only
2. Dresses with help for fasteners only
3. Knows most body parts
4. Opens simple containers with screw top or snap top lids
5. Can open/close simple fasteners (zipper, Velcro, hook)
6. Drinks from a normal cup without spilling
7. Puts shoes on correct feet, completely
8. Laces and ties shoes
9. Brushes teeth with horizontal and vertical motions
10. Combs and brushes hair well
Activity Not Expected Child Needs Help All/Most of the Time Child Needs Help 50% of the Time Child Needs Help Occasionally Child Performs Task Without Help
11. Does simple household chores; dust, vacuum, pick up
12. Cares for grooming needs; hair, skin, nails
13. Can bathe and wash body
14. Can wash hair by self
15. Washes hands before eating and after getting messy
16. Prepares simple snacks for self
17. Cuts food with knife and eats with fork or spoon
18. Toilets by self, given mild help for cleaning up
19. Can organize and put away groceries, food, supplies
 
 
 
What are your top concerns in regard to school & productivity?
   
What are your top concerns in regard to work & social participation?
   
What are your top concerns in regard to sports/play/leisure?
   
What are your top concerns in regard to self-care/independence?
   
Other comments or concerns:
   
 
 
Name of person completing this feedback form:
* First Name : 
* Last Name : 
 
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