dchk

Sample Daily Checklist

Name: _________________Date:___________ Completed by:___________________________________

Current IEP Goals

Communication-increasing phrase length 3-5 words, answer questions, maintain eye contact, express needs
Social/Play Skills-interacting and initiating play with peers through teacher directed assistance, use toys and materials appropriately
Fine Motor-using functional grasp with writing utensils and scissors, complete 12 piece inset puzzle
Self Help-toilet, hand washing, dressing/undressing with use of visual and verbal prompting
Attending-remain with group, attend to task

Activities at Circle time-

Small Group Activity-                                                                                                                              *Did he have ST__or OT__ today?
                                                                                                                                                        **ST & OT** Write comments on back

Outside activity-                                                                                  Indoor activity-

*******    Please write any teacher comments on the back of this checklist*************

Did _______ participate at circle?
Yes__No__ SW__(SW=Somewhat)
If No, why?
Distracted___ Upset___
Frustrated___ Uninterested__
Observing ___ Staring off__
Out of his seat___
Other:

Able to answer questions asked during
the day?
Yes__ No___ SW__Echolalic___
Answered in 3-5 word sentences using
meaningful speech?
Yes__ No___ Mixture__
Answered direct Yes/No questions?
Yes__ No___ Somewhat___

Fine motor performance
Able 2 use manipulatives?
Yes__ No_-_ SW__
Able to complete puzzles?
Yes__No__SW__
Able to use proper grasp when
writing/coloring?
Yes__No__SW __Other:

Cognitive Ability
Counts w/ 1 on 1 correspondence?
Yes__No__SW__
Able to recall info or part of his day?
Yes__No__SW__
Other:

Able to use materials appropriately?
Yes___ No___ Somewhat____
If No, why? (check all that apply)
Unable to focus__
Out of his seat__
Fine Motor difficulty__
(circle one)
Pincer grasp, Use of scissors
Other:
Sensory related__
(circle one)
Mouthing, smelling, tactile sensitivity
Other:

Length of time attended to task
for small group:
1-5 minutes___ 5-7minutes___
7-10 minutes___ 10-15 minutes___
15 minutes or more___
Able to complete task given?____
------------------------------------------
*****Teacher Comments*****

Teacher/ST/OT strategies
Hand over hand assisted___
One on one physical demonstration of task to perform___
One on one verbal instruction of task to perform___
Able to perform task through verbal group direction/instruction___
Other:
___________________________________
Bathroom/Handwashing
Today Chase was able to use the bathroom:
Independently___ With physical assistance___
Verbal prompting___Visual prompting___
washed hands-Independently__Physical asst__ Verbal
prompting___ Visual prompting__
Comments:

Type of peer interaction
facilitated by teachers:
Prompted ____________ to interact
with another child? Yes__ No___Did
not facilitate today___
Prompted another child to interact
with ___________? Yes____ No___
No prompt needed today,
___________ initiated it on his
own____

Outcome of peer interaction
Outside:
Played interactively for ___min.
Preferred to play alone _____
Preferred to play alongside_____
Used playground equipment appropriately and purposefully?
Yes___ No___ Somewhat____
Inside:
Played interactively for____ min.
Preferred to play alone _____
Preferred to play alongside_________

Strategies used by teachers

Physically modeled appropriate
friend/interactive behavior____
Used visual cues to show appropriate
social or play behavior____
Used verbal cues/redirection to facilitate
peer interaction ____and/or functional
play___
Other:

Eating- ate well ___ate some___ ate little__
Tried new food? Yes___ No___ If yes, what?

Nap-slept_rested quietly__restless__talkative__wandered_
How did __________ spend his nap?