Student ____________________________________________________Grade ___________________
Class/location observed (include teacher name) _____________________________________________
Observer name and title ______________________________________ Date of observation _________
This tool is designed for use as a guide during a student observation. You may not see all domains addressed, however, the student should be observed during times when you will be able to monitor behaviors related to the area of concern. If the child is 3-5 years old and not yet in school the observation should be conducted in the child’s natural environment or early intervention program.
In order to obtain a full and accurate picture of the student’s performance, it may be necessary to observe the student more than once, in different settings and at different times of the day. Multiple observation forms may be included in the evaluation documentation.
Directions: First identify the area(s) of concern for the student. Behavior around each identified area is where you will focus your observation. During the observation place a check mark next to the behaviors that are observed within each domain that correlates with the noted areas of concern. Note, however, these checklists are not exhaustive. In the notes section, write any additional observed behavior, including strengths, which may be relevant to the student’s evaluation.
Check area(s) of concern as identified in SLD 2.
___ Oral Expression ___ Written Expression
___ Basic Reading
___ Reading Fluency Skills ___ Listening Comprehension
___ Mathematics Problem Solving ___ Mathematics Calculation
Language (Oral Expression, Basic Reading
q Age Appropriate
q Has difficulty modulating voice (i.e. too soft, too loud)
q Has trouble naming people or objects
q Has difficulty staying on topic
q Inserts invented words into conversation
q Has difficulty re-telling what has just been said
q Demonstrates slow and halting speech, using lots of fillers (i.e., uh, um, and, you know)
q Mispronounces words frequently
q Has difficulty rhyming
q Has limited interest in books or stories
q Has difficulty understanding instructions or directions
Notes:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
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Reading (Basic Reading
_ Age Appropriate
_ Confuses similar-looking letters and numbers
_ Demonstrates poor memory for printed words
_ Has trouble naming letters
_ Has problems associating letters and sounds, understanding the difference between sounds in words or blending sounds into words
_ Has poor retention of new vocabulary
_ Dislikes and avoids reading or reads reluctantly
Notes:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
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Written Language (Written Expression)
_ Age Appropriate
_ Dislikes and avoids writing and copying
_ Has difficulty remembering shapes of letters and numerals
_ Frequently reverses letters, numbers and symbols
Notes:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
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Math (Math Calculation, Math Problem Solving)
_ Age Appropriate
_ Has difficulty with simple counting and one-to-one correspondence between number symbols and items/objects
Notes:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
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Social Emotional (All Areas)
_ Age Appropriate
_ Has difficulty ‘joining in’ and maintaining positive social status in a peer group
_ Has difficulty with self-control when frustrated
Notes:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
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Attention (All Areas)
_ Age Appropriate
_ Has difficulty sustaining attention in work tasks or play activities
Notes:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
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Gross and Fine Motor Skills (All Areas)
_ Age Appropriate
_ Appears awkward and clumsy, dropping, spilling, or knocking things over
_ Has trouble with buttons, hooks, snaps, zippers and trouble learning to tie shoes
_ Creates art work that is immature for age
_ Demonstrates poor ability to color or write ‘within the lines’
_ Grasps pencil awkwardly, resulting in poor handwriting
_ Experiences difficulty using small objects or items that demand precision (i.e., Legos, puzzle pieces, tweezers, scissors)
Notes:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
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Other notes or observed behavior
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