FUNCTIONAL SKILLS CHECKLIST
Adapted from various inventories including the Brigance
Student:
Grade:
Date:
Teacher:
1. Motor Skills *Also see Occupational Therapy Report, if available
Personal Care / Self Help:
Dressing:
⃞ Takes shoes / boots off
⃞ Puts shoes / boots on
⃞ Takes jacket off
⃞ Puts jacket on
⃞ Takes backpack off
⃞ Puts backpack on – with some assistance
Fastening:
⃞ Manages large front buttons
⃞ Attempts to tie shoes
⃞ Velcros shoes closed
⃞ Ties shoes
⃞ Zips up front zipper
Eating:
⃞ Feeds self snacks
⃞ Lifts cup or glass from table
⃞ Spoon feeds without spilling
⃞ Opens containers
⃞ Puts left over food away (garbage or back into containers)
Toileting:
⃞ Knows when he/she needs to go and communicates this in some way
⃞ Needs help with all clothing
⃞ Pulls down pants
⃞ Attempts to wipe self
⃞ Cares for toileting needs other than help for wiping
⃞ Flushes toilet
⃞ Manages clothes adequately on own
⃞ Needs standby help
Fine Motor
⃞ Manipulates small toys / items (large lego, toy figurines...)
⃞ Puts items together (building blocks, interlocking blocks, large puzzles...)
⃞ Scribbles
⃞ Scribbles – seldom going off page
⃞ Traces lines
⃞ Traces some letters
⃞ Traces circles
⃞ Traces name
⃞ Copies some shapes
⃞ Copies some letters
⃞ Copies name
⃞ Colors simple shapes, mostly within the lines
2. General Knowledge and Comprehension
Personal Data
⃞ First name
⃞ Full name
⃞ Sex
⃞ Age
⃞ Siblings
Vocabulary: Matching
Body Parts: Pointing To (Receptive) / Naming (Expressive)
1. mouth
6. tongue
11. arms
16. chin
2. eyes
7. head
12. fingers
17. tongue
3. nose
8. ears
13. stomach / tummy
18. hair
4. feet
9. hands
14. back
5. toes
10. legs
15. teeth
Colours: Pointing To (Receptive) / Naming (Expressive)
1. red
3. green
5. orange
7. brown
2. blue
4. yellow
6. purple
8. black
Shape Concepts: Pointing to (Receptive) / Naming (Expressive):
1. circle
2. square
3. triangle
Quantitative Concepts
1. one / many
2. little / big
Directional / Positional Concepts
1. open / close
3. in / out
4. behind / in front of
2. front / back
4. up / down
6. over / under
Sorting / Classifying
1. Colours
2. Shapes
3. Animals
4. Toys
5. Cars / trucks
Readiness
Recites Alphabet
Recognizes Letters
Receptive:
Upper Case Lower Case Expressive
Upper Case Lower Case Word Recognition:
Approximate Grade Level Or
Estimated Number of Sight Words that student recognizes Reads Colour Words:
Reads Number Words:
Reads Calendar Words (days, months):
Reads Common Signs:
Go
Stop
In
Walk
Wait
Caution
Out
Boys
Danger
Literacy Skills:
⃞ Looks at books – right side up
⃞ Turns pages individually
⃞ Points to specific pictures on request
⃞ Names pictures
Girls
Exit
Enter
Men
Women
⃞ Takes part in read by ‘filling in’ words and phrases
⃞ Tries to read book from memory
Printing:
First Name:
Age:
Last Name:
Phone Number:
Lower Case Letters Dictated:
Upper Case Letters Dictated:
Simple Sentence:
Arithmetic:
Counts Objects to: ___________
Rote Counts to: ___________
Reads Numerals to (estimated):
Numeral Comprehension (matches quantity) to
Writes Numbers in Sequence to
Writes Numerals Dictated
Addition Combinations to
Subtraction Combinations to
Recognition of Money:
Tells Time:
FUNCTIONAL SKILLS SUMMARY FORM
Student:
Date:
Personal Care / Self Help Skills to be worked on
1
2
3
4
Fine Motor Skills to work on…. please consult with OT/PT
1
2
3
4
Gross Motor Skills to work on…. please consult with OT/PT
1
2
3
4
Personal Knowledge…. Name, age, family members… to be learned
1
2
3
4
Early Learning - including Vocabulary and Concepts (objects, colours, etc) to be worked on
1
2
3
4
5
Functional Academics…. Early Literacy and Numeracy Skills to be worked on
1
2
3
4
Communication Skills to be worked on (consult SLP)
1
2
3
4
Assistive Technology Skills to be worked on (consult SET-BC)
1
2
3
4
Home and School Safety Skills to be acquired
1
2
3
4
Neighborhood Awareness and Safety to be acquired
1
2
3
4
Leisure Skills to be acquired
1
2
3
4
Community Awareness and Safety to be acquired
1
2
3
4