This free survey is powered by
  1. Surveys
  2. 2014
  3. July
  4. P
  5. Parent Feedback Form (8-14+) 080414
0%
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 8-14+ 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. Prints with a pencil or pen legibly
2. Prints words and simple phrases
3. Draws complex pictures with parts and details
4. Completes and manages homework on time
5. Exhibits flexible problem solving abilities
6. Exhibits cooperative interaction in groups
7. Able to regulate behavior in difficult situations
8. Brings home books and supplies for homework
9. Prepares back pack and lunch for school
10. Can copy assignments from blackboard
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. Composes and writes creative stories
12. Remains seated in school without distraction
13. Respects equipment and supplies that belong to others
14. Follows rules and regulations in the community
15. Can perform research from prompts
16. Able to identify different solutions to a problem
17. Can complete simple keyboarding
18. Persists when tasks are challenging
19. Organizes and studies for tests effectively
20. Creates and follows timelines for long-term projects
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
21. Performs topical research online
22. Establishes short-term (immediate) goals
23. Establishes long-term (later) goals
24. Exhibits goal-directed behavior
25. Transitions between places/people/events effectively
26. Keeps track of belongings when away from familiar places
27. Uses effective study skills
28. Studies from own notes effectively
29. Takes organized notes
30. Understands what he/she reads
31. Signs name in cursive
32. Prints full name
 
 
Section 8-14+ 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. Helps younger siblings with routines
2. Can feed and water pets
3. Participates in clubs and community organizations
4. Completes a familiar goal or routine from beginning to end
5. Exhibits positive social skills with individuals that are familiar
6. Uses appropriate social skills with individuals that are unfamiliar
7. Able to follow directions
8. Less self-centered and willing to adapt for others
9. Exhibits executive function capacities; thinking, problem solving, memory, reasoning.
10. Can complete a simple fill-in form or worksheet
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. Follows a schedule accurately
12. Respects personal space
13. Asks and answers questions to get needs met
14. Learns from modeling or demo
15. Separates emotion from work tasks
16. Adapts voice, body, direction, and force to the demand or place
17. Manages small amounts of money to buy things
18. Helps out with chores around the house that take less than one hour
19. Inhibits/self-regulates own behavior
20. Can run simple errands and perform familiar jobs
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
21. Organizes information sequentially to get work done
22. Compares and contrasts different ideas
23. Organizes information into categories
24. Understands cause and effect relationships
25. Listens effectively
26. Expresses ideas effectively
 
 
Section 8-14+ 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. Uses electronics to play games, answer phone, email
2. Plays computer games with challenges and problem solving
3. Has collections or hobbies
4. Exhibits cooperative and competitive play
5. Competent in using balls to play games (soccer, baseball, etc.)
6. Enjoys telling stories and sharing jokes
7. Plays with consistent friends cooperatively
8. Hand manipulation for crafts and construction
9. Builds with blocks and connecting toys by copying patterns
10. Rides a 2-wheel bike
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. Enjoys gymnastics and tumbling
12. Can propel self on skates or scooters
13. Able to climb up high and get down again
14. Runs toward a goal or object upon command
15. Develops self-interests: martial arts, cheer, playing a musical instrument, horseback riding, etc.
16. Plans and organizes leisure time activities
17. Avoids reckless or risky behaviors
18. Able to safely babysit younger siblings
19. Remembers changes in daily schedule
20. Follows rules, directions, guidelines
 
 
Section 8-14+ 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. Dresses and undresses, including fasteners
2. Opens simple containers with screw top or snap top lids
3. Uses utensils to cut food and eat it
4. Opens and closes a water bottle
5. Drinks from wide mouthed containers
6. Manages shoes and sandals of all types
7. Laces and ties shoes by self
8. Flosses and brushes teeth
9. Attends to cleaning hands and face as needed
10. Combs, brushes, or styles hair
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. Completes regular household chores
12. Cares for grooming needs; hair, skin, nails
13. Can wash and condition hair
14. Follows 4+ steps from beginning to end
15. Can pour a drink
16. Can make bed and pull sheets off bed
17. Can fold and hang up clothes
18. Empties trash and carries it outside
19. Can follow steps to prepare and clean up a snack
20. Cares for glasses, contacts, or hearing aids
21. Able to use a microwave or stove top safely
22. Can set and clear the dinner table
23. Can clean up a mess as directed
 
 
 
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 : 
 
Share This Survey:          Survey Software Powered by QuestionPro Survey Software