A.
Auditory
Almost Always
Frequently
Occasionally
Seldom
Almost Never
1
Misses oral directions in class more than other students
2
Appears to not hear what you say (e.g., does not tune in to what you say, appears to ignore you)
3
Seems oblivious within an active environment (i.e., unaware of activity)
4
Hums, whistles, sings, or makes other noises throughout the day
5
Is distracted or has trouble functioning if there is a lot of noise in the area
6
Tells others to be quiet
7
Becomes distressed during assemblies, lunch, or other large gatherings
8
Is overly bothered by loud or unexpected noises (e.g., fire alarm, books slamming to the floor, doors slamming, announcements, bells)
9
Has difficulty participating in group activities where there is a lot of talking
10
Holds hands over ears to protect them from sound
B.
Visual
Almost Always
Frequently
Occasionally
Seldom
Almost Never
11
Misses written or demonstrated directions more than other students
12
Has trouble keeping materials and supplies organized for use during the day
13
Leaves items blank on a busy worksheet even when he or she knows the answers
14
Doesn’t watch during instruction, but follows through with activities
15
Adds more details to drawing and coloring than other students
16
Watches other students when they move around the room
17
Notices even small changes in the room or desk organization
18
Comments on small details in objects or pictures that others haven’t noticed
19
Looks away from tasks to notice all other activity in the room
20
Startles at unexpected movements near desk or around room (e.g., another student getting up quickly, objects fall off desk)
21
Avoids eye contact
C.
Movement
Almost Always
Frequently
Occasionally
Seldom
Almost Never
22
Is clumsy and awkward in movements (e.g., runs into desks and furniture when moving about)
23
Slouches, slumps, or sprawls in chair
24
Rests head in hands on desk or table during class time and seatwork
25
Runs or bumps into things (e.g., walls, doors, equipment, other people)
26
Seeks all kinds of movement, which interferes with daily routines (e.g., can’t sit still, fidgets)
27
Is “on the go”
28
Fidgets during activities (e.g., moves around, taps on desk)
29
Gets up and moves around more than other students
30
Seems to find excessive reasons for approaching the teacher
31
Stands or sits at the side of the playground during recess
32
Withdraws from activities
33
Is slow to participate in physically active tasks or activities
34
Intentionally withdraws from active environments or situations (e.g., retreats to a quiet area in the classroom)
35
Refuses to participate in team games (e.g., soccer or basketball)
D.
Touch
Almost Always
Frequently
Occasionally
Seldom
Almost Never
36
Does not steady objects when working (e.g., does not hold paper down when writing)
37
Comes too close into other people’s personal space when talking
38
Doesn’t seem to notice when face and hands remain soiled
39
Touches people and objects to the point of irritating them
40
Plays or “fiddles” with objects or school supplies (e.g., pencils, notebooks, folders)
41
Displays unusual need to touch certain toys, surfaces, or textures (i.e., constantly touching objects)
42
Is fidgety or disruptive when standing in line or close to other people (e.g., getting on the bus, sitting in an assembly)
43
Wants to wipe hands quickly or often during messy tasks
44
Is easily upset by minor injuries (e.g., bumps, scrapes, cuts)
45
Uses only fingertips to work on projects that require manipulation
46
Flinches when you get in close proximity or touch his or her body
47
Refuses to participate in activities that are messy (e.g., art projects, using glue or paint)
E.
Behavior
Almost Always
Frequently
Occasionally
Seldom
Almost Never
48
Is inefficient in doing things (e.g., wastes time, moves slowly, makes tasks more complicated)
49
Appears inactive (i.e., seems to lack energy)
50
Shows little emotion regardless of the situation
51
Seems more curious than other students
52
Is bothered by rules being broken
53
Is bossy with classmates or peers
54
Can be described as over-reactive or dramatic when compared to classmates or peers
55
Doesn’t express emotions (i.e., has a flat, unresponsive affect)
56
Doesn’t have a sense of humor
57
Can be described as inflexible when compared to classmates and peers
58
Has difficulty tolerating changes in routines, plans, and expectations
59
Is stubborn or uncooperative
60
Perseverates to the point that he or she cannot move on (i.e., can’t shift gears)
61
Withdraws when there are changes in the environment or routine
62
Is frustrated easily