Iredell-Statesville Schools  Early Admission to Kindergarten
Early Screening Profile
To be completed by preschool teacher, child care worker, pediatrician,
or other adult with direct knowledge of the child.
This questionnaire helps us to know how well this child takes care of himself/herself and gets along
with others. It is important that you respond carefully. Each statement asks whether the child does these
activities, not whether he/she can do them. Please be sure to respond to each item, even if the activity
seems too old or too young for the child. A score of “2” indicates that the child performs the activity
without help and without being reminded. (Adapted from AGS Early Screening Profiles and NashRocky Mount Public Schools)
Child’s Name
Date of Birth
Person Completing Form (please print)
Relationship to Child
School or Organization
Scoring: 0 = Never or Almost Never; 1 = Sometimes or Partially; 2 = Almost Always or Always
0
Description of Child’s Behavior
Socialization
Labels happiness, sadness, fear and anger in himself or herself and why; for example, says,
“I’m happy today because…”
Identifies people by characteristics other than name; for example, says, “That’s Elizabeth’s
sister.”
Has a best friend of the same sex.
Has a fairly regular group of friends.
Plays at least one game or activity with others.
Takes part in elaborate make-believe activities alone or with others.
Follows the rules of simple games.
Shares toys or possessions without being told to do so.
Watches television for information about a particular area of interest; for example, a wild
animal or sports figure.
Uses appropriate table manners without being told.
Responds appropriately when introduced to someone new; for example, says, “Hello! It’s nice
to meet you.”
Ends conversations appropriately; for example, says, “Goodbye. See you soon.”
Apologizes for unintentional mistakes; for example, says, “Excuse me” after bumping into
someone.
page 1 of 2
1
2
0
Description of Child’s Behavior
Daily Living Skills
1
Drinks from cup or glass with little spilling.
Cares for all toileting needs, including flushing and washing hands.
Fastens all fasteners, including zippers.
Communication
Pays attention to a story for at least 5 minutes.
Pays attention to a lecture, speech or sermon for at least 15 minutes.
Says own first name and last name when asked.
Speaks in full sentences.
Tells experiences in detail when asked; for example, describes what he or she did during the
day.
Says complete home address, including city and state, when asked.
Motor Skills
Uses scissors to cut out complex items; for example, pictures from a magazine.
Draws at least two recognizable objects, such as an animal or a house.
Can write his/her name.
Completes a jigsaw puzzle with at least 6 pieces.
Builds three-dimensional structures, such as a house or bridge, using at least five blocks.
Jumps over small objects.
Hops on one foot with ease.
Catches small ball thrown from a distance of ten feet.
Runs smoothly, with changes in speed and direction, when necessary.
Based on your interaction with this child, would you recommend him/her for early admission to
kindergarten? Keep in mind the child’s ability to function independently in a group setting for an entire
school day. Please elaborate on your response.
Signature of Person Completing the Form
Date
page 2 of 2
2