Children first school

SPECIAL EDUCATION PROGRAM

FORM 1: TEACHER NOMINATION
Directions:
1. Read the Checklist thoroughly. Ask the Special Education Teachers to explain the items that
are not quite clear to you.
2. Write the Names of your pupils/students who show most (more than half) of the
characteristics in the Checklist.

NAME GRADE/ YEAR LEVEL AGE CLASS ADVISER

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NAME GRADE/ YEAR LEVEL AGE CLASS ADVISER

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Children First school

SPECIAL EDUCATION PROGRAM
FORM 2: CHECKLIST ON LEARNING AND BEHAVIOR CHARACTERISTICS (CLBC)

Directions:
Check the items under the proper column of observed learning and behavior
characteristics of your pupil/ student.

CHARACTERISTICS SOMETIMES MOSTOF THE ALL OF THE

(1 POINT) TIME TIME
(2 POINTS) (3 POINTS)
I. LEARNING CHARACTERISTICS
A. Spelling
1. Uses incorrect letter order
2. Cannot spell correctly at grade level
3. Cannot write from dictation at grade level
4. Reverses letters or entire words
B. Writing
1. Cannot write name or other information
2. Cannot stay on line
3. Cannot copy simple sentences from the board
4. cannot write simple sentences from dictation
5. Cannot do regular work in writing for the
grade
C. Reading
1. Does not like to read
2. Loses place when reading
3. Repeats, omits or adds words
4. Cannot repeat the Dolch words for grade level
5. Uses fingers to follow a line
6. Cannot understand/ remember what he/she
reads
D. Mathematics
1. Has difficulty associating numbers with
symbols
2. Reverses two-place numbers
(13 for 31 or vice versa)
3. Cannot recall math facts at grade level
4. Fails to comprehend math concepts
5. Gets confused with written and/or oral
arithmetic

CHARACTERISTICS SOMETIMES MOSTOF THE ALL OF THE

(1 POINT) TIME TIME
(2 POINTS) (3 POINTS)
E. Hearing/Speech
1. Does not seem to listen when spoke to
2. Cannot follow oral direction
3. Has articulation problems; wrong
pronunciation of words; speech not clear
4. Has infantile (baby) speech
F. Psychomotor
1. Displays poor motor coordination in using
scissors, crayons, pencil, etc.
2. Confuses right from left and vice versa
3. Lacks rhythm in movement, loses sequence
and balance; has difficulty walking in straight
line
4. has difficulty buttoning, zipping, and snapping
articles of clothing; skipping, hopping, climbing
II. BEHAVIOR CHARACTERISTICS
1. Tends to be impulsive, hits classmates, reacts
immediately to situations without thinking;
impatient; cannot wait for his/her turn
2. Demands individual attention through overt
behavior tactics
3. Rushes through assignments with little or no
regard for accuracy, quality of work and
neatness
4. Does not direct attention to or cannot
maintain attention to important sounds in the
immediate environment, teachers directions,
public addresses
5. Has short attention span, has difficulty
concentrating on tasks (e.g. more interested in
other activities, sits and does nothing, etc.)
6. Stays out of seat; engages in over active
behavior

Additional information about the pupil

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Scoring and Interpretation of results:

Scoring Procedure:
1. Add the number of checkmarks in each column and multiply the sum by the
number of points.
Sometimes- - - - - - - - - - - - - - - - x 1
Most of the time- - - - - - - - - - - -x 2
All the time- - - - - - - - - - - - - - - -x 3
2. Write the score using the following ranges and interpretation.

Interpretation:

75-105 points Manifests almost all of the LD characteristics.

Recommended for multi-factored assessment
50-74 Manifests most of the LD characteristics.
Recommended for multi-factored assessment
35 and below Manifests some of the LD characteristics.
Can benefit from regular class instruction
 Children First School
SPECIAL EDUCATION PROGRAM
FORM 3: SUMMARY REPORT ON PRE-REFERRAL SCREENING (SR-PRS)

Directions:
Write the names, grade levels and age of the pupils/ students who passed the pre-
referral phase. Write the scores obtained in the initial screening tools.

NAME GRADE/YEAR AGE SCORE REMARKS

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Children First School

SPECIAL EDUCATION PROGRAM
FORM 4: INDIVIDUAL REPORT ON PREREFERRAL SCREENING (IR-PRS)

Name of Student: _____________________________ Date of Birth: __________________

Age: __________ Gender: _____________ Grade/ Year level: ______________
Home Address: _________________________________________________________________
______________________________________________________________________________
Fathers Name: _________________________ Mothers Name: ______________________
Guardians Name: _________________________ Contact Number: _____________________
Initial Screening Score: __________ Interpretation: _____________________________
Learning Characteristics:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Behavior Characteristics:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Recommended for multi-factored assessment: yes no
Other Observations:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

____________________________________
Teachers Signature over Printed Name
____________________
Date

Child First School

SPECIAL EDUCATION PROGRAM
FORM 5a- CHILDS PROFILE: CASE HISTORY FORM (CHF)

CHILDS PROFLE:
Childs Name: _________________________________ Date of Birth: __________________
Age: ____________ Gender: ______________ Education: ____________________
Home Address: ________________________________________________________________
_____________________________________________________________________________
Contact Number: _______________________________

Reasons for Referral:

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

I. GENERAL
Fathers Name: ________________________________________ Age: _____________
Date of Birth: ____________________________ Birthplace: __________________________
Address: ______________________________________________________________________
Education completed: _____________________ Citizenship: __________________________
Occupation: _____________________________ Office Address: _______________________
Contact Number: _________________________

Mothers Name: ________________________________________ Age: _____________

Date of Birth: ____________________________ Birthplace: __________________________
Address: ______________________________________________________________________
Education completed: _____________________ Citizenship: __________________________
Occupation: _____________________________ Office Address: _______________________
Contact Number: _________________________

Brothers/Sisters
Name: ____________________________________ ___ Gender: __________ Age ________
Name: ____________________________________ ___ Gender: __________ Age ________
Name: ____________________________________ ___ Gender: __________ Age ________
Write the letters in the presence of
M for Mother F for Father S for Sibling
G for Grandparent R for Relatives

Hearing Loss __________ Visual Impairment __________

Epilepsy __________ Mental Illness __________
Autism __________ Mental Retardation __________
Substance Abuse __________ Clinical Depression __________
Fragility __________
Speech Impairment (please specify) ________________________________________
Behavior Problems (please specify) ________________________________________
Academic Difficulty (please specify) ________________________________________
Specific Learning Disorder (please specify) ________________________________________
Others (please specify) ________________________________________

DEVELOPMENTAL HISTORY
A. HISTORY
Age of mother at childs birth: __________ Age of father at childs birth: __________
Pregnancy length: __________ Birth weight: __________
Was labor induced? Yes No

Were there any accidents, illnesses, infections, special tests during pregnancy or delivery?
(Please explain)
______________________________________________________________________________
______________________________________________________________________________
Did the infant have any difficulty in breathing, crying, and sucking? (Please explain)
______________________________________________________________________________
______________________________________________________________________________

Did the infant have jaundice, convulsions, blood incompatibility, etc.?(Please explain)
______________________________________________________________________________
______________________________________________________________________________

B. BIRTH
Was the baby full term? __________ Premature? ___________
Was it a difficult labor? _____________________________________________________
Was delivery normal? __________ Caesarian Section? ___________
What anesthesia was used (if any)? ________________________ When? ___________
Were instruments used to assist normal delivery (if any)? ______________________________
Did baby suffer from lack of oxygen? _______________________________________________
Did baby cry right away after birth? ________________________________________________
Did baby appear normal at birth? __________________________________________________

C. ILLNESSES/ INJURIES
CONDITION AGE DESCRIPTION
Allergy _______________ ________________________
Ear Infection _______________ ________________________
Encephalitis _______________ ________________________
Epilepsy _______________ ________________________
Fainting Spells _______________ ________________________
Hearing Problems _______________ ________________________
High Fever _______________ ________________________
Meningitis _______________ ________________________
Muscular Disease _______________ ________________________
Seizure _______________ ________________________
Syndromes _______________ ________________________
Tonsillectomy/ Adenoidectomy _______________ ________________________
Traumatic Brain Injury _______________ ________________________
Brain Problems _______________ ________________________
Other (Please specify) _______________ ________________________

Describe any accidents or operations including dates: __________________________________

______________________________________________________________________________
List any medications prescribed for the child: _________________________________________
______________________________________________________________________________
Were high doses of antibiotics ever prescribed? Yes No
If yes when? ________________________ What antibiotic/s? ____________________
Why were they prescribed? _______________________________________________________
During the first two years, did the child ever have prolonged high fever? (If yes, please explain)
______________________________________________________________________________
______________________________________________________________________________
What preventive measures (i.e. immunization, vaccinations, etc.) have been taken?
______________________________________________________________________________
______________________________________________________________________________
Has the child any serious reaction to immunization? If so, when? _________________________
Operations performed and reasons for these? ________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

C. PRESENT PHYSICAL CONDITION

Allergies: ____________________________________________________________________
Preference for right or left hand: _________________________________________________
Noticeable problems in coordination: _____________________________________________
Does the child fall easily? Yes No
Does the child drool excessively? Yes No
Does the child over-perspire? Yes No
Does the child seem tense? Yes No
Does the child have normal vision? Yes No
Does the child have normal breathing pattern? Yes No
Does the child sniff food or objects frequently? Yes No

ILLNESSES DATE COMPLICATION NAME AND ADDRESS OF

 ATTENDING PHYSICIAN

D. MOTOR MILESTONES
Indicate the age at which the following occurred:

Roll over __________ Fed self __________

Sat alone __________ Crawled __________
Handedness __________ Dressed self __________
Walk unaided __________ Toilet trained __________

E. SPEECH/LANGUAGE DEVELOPMENT
Indicate the age at which the following occurred:
Cooing _______________________ Babbling __________________________
First words __________________________________________________________________
Vocabulary of 50 words: Understood ___________ Said ____________
Two-word combinations (i.e. more milk, me do, no go): ______________________________
Short sentences (i.e. I want juice, mommy do it): ______________________________

RECEPTIVE AND EXPRESSIVE LANGUAGE SKILLS

Please answer yes, no, or sometimes to the following questions. Asterisk (*) signifies a
follow-up question. Explain your answers if necessary.

Does your child respond to his/her name? ____________

Will your child get common objects when asked? ____________
Does your child follow simple directions if you use gestures? ____________
Does your child follow simple directions if you do not use gestures? ____________
Does your child use gestures? ____________
Will your child point to pictures as you name them? ____________
Does your child label pictures? ____________
Does your child repeat or echo others utterances? ____________
Does your child repeat questions or parts of questions, songs, TV programs? ____________
Has your child said a word few times then never use it again? ____________
*If yes, when? _____________________ *What words? ______________________________
Did language development seem to stop? ____________
*If yes, when? __________________________________________________________________
Does any in the household speak a language other than your dialect? ____________
*If yes, what dialect/s? __________________________________________________________
How does your child make his/her needs/wants known to you? __________________________
______________________________________________________________________________
How does your child indicate he/she does not want something or does not want to do
something? ____________________________________________________________________
______________________________________________________________________________
What words/sentences does your child say independently (not reciting) without your prompting
or modeling? __________________________________________________________
______________________________________________________________________________
Has your child ever had an audiological evaluation (hearing test)? __________________
*If yes, when and where? ______________________________________________________
Has your child ever had any speech/language testing? __________________
*If yes, when and where? ______________________________________________________
Has your child had any speech/language therapy? __________________
*If yes, when and where? __________________

F. BEHAVIORAL INFORMATION
1. Infancy
Please answer yes, no, or sometimes to the following questions:

Was a silent infant _______________

Was an inconsolable infant _______________
Was too happy as an infant _______________
Rarely cried _______________
Did not desire interaction/affection _______________

Comments:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

2. Play
Please answer yes, no, or sometimes to the following questions:
Prefers to play alone _______________
Plays poorly with other children or does not interact with others _______________
Frequently lines items in a row _______________
Protests if line of items is interrupted _______________
Holds (clutches) items for an extended period of time _______________
Frequently counts (objects, items, actions, etc.) _______________
Has unusual interest (strips of paper, electrical cords, etc.) _______________
Waves long objects back and forth _______________
Spins objects _______________
Circle any of the following which applies to your childs play:

Repetitive With a small group Messy

Imaginative Fantastic As a follower
Cooperative With toys As a leader
With peer group Flitting Others
With other children Engrossed

Comments:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

3. Conduct
Please answer yes, no, or sometimes to the following questions:

Is difficult to manage _______________

Has behavior problem _______________
Displays temper tantrums _______________
Has catastrophic reaction when told no _______________
Discipline is ineffective _______________
Is overly active _______________
Has short attention span _______________
Is aggressive toward self _______________
Is aggressive toward others _______________
Is destructive with objects _______________

Check () any of the following which describes your child.

_____ Negative _____ Manipulative _____ Fearful
_____ Quiet _____ Passive _____ Destructive
_____ Excitable _____ Leader _____ Aggressive
_____ Active _____ Friendly _____ Happy
_____ Self-centered _____ Predictable _____ Generous
_____ Sad _____ Suggestible _____ Stubborn
_____ Confident _____ Temper tantrums _____ Unresponsive
_____ Lack Confidence
_____ Others (please specify) _____________________________________________________
Comments:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

4. General
Please answer yes, no, or sometimes to the following questions:

Is withdrawn __________
Grinds teeth __________
Rocks back and forth __________
Frequently spins in circles __________
Has difficulty with change/ transitions __________
Protests when dressing/ undressing __________
Acts as if deaf __________
Acts as if in his/her own world __________
Ignores someone talking to him/her __________
Covers ears with his/her hands __________
Has limited eye contact __________
Repeatedly turn lights on/off __________
Stares at his/her fingers/hands __________
Stares intently at people/objects __________
Stares at self in the mirror for long periods of time __________
Have strong preferences for/responses to specific color __________
Has strong preference for specific food temperature, shape, color, texture, etc. __________

Comments:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

5. Fears
Please answer yes or no to the following questions:

Climbs without fear __________

Has an unusual fear (specific animals, places, noises, colors, etc.) __________
Exhibits age-appropriate fears (separation, being lost, darkness, etc.) __________

Comments:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

HOME SITUATION
Please answer yes or no to the following questions. Asterisk (*) signifies a follow-up
question. Explain your answers if necessary.

Has the child always lived with both parents? ____________

Had there been sudden departures or deaths in the immediate family? ____________
Are there or has there been any serious illness in the family? ____________
Has the child a younger sibling? ____________
*Who prepared him for siblings birth? __________________________________________
*Who took care of the child while mother is in the hospital? ________________________
*Was there any noticeable change in the childs behavior after the birth of the baby? ________
*What was the childs reaction to the new baby? ____________________________________
Have there been sudden changes, relocations of family, home, etc. during the growth and
development of the child? ____________
*What was the childs reaction to these changes? _____________________________________
*Between the parents, to whom is the child more attached at present? ___________________
*Was it always like this? ____________

EDUCATIONAL HISTORY
Age the child entered school __________________________________________
Initial reaction of the child toward school __________________________________________
Early intervention program/s __________________________________________
Daycare/Preschool __________________________________________

Schools Attended Inclusive Dates

_____________________________________ ______________________________
_____________________________________ ______________________________
_____________________________________ ______________________________
_____________________________________ ______________________________
_____________________________________ ______________________________
_____________________________________ ______________________________
Did the child repeat any grade school? __________ Which? _______________________
Why? _________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Which subjects does he/she enjoys most? __________________________________________
In which subject does he/she excel? __________________________________________
Which subjects does he/she has most difficulty? ____________________________________
What are his/her reactions to his/her teachers? ____________________________________
______________________________________________________________________________
What are his/her reactions to classmates? __________________________________________
______________________________________________________________________________

Current Educational Placement __________________________________________

Current Teacher/s __________________________________________
______________________________________________________________________________
Other Special Programs __________________________________________
______________________________________________________________________________

OTHER INFORMATION
Please provide other information that you feel would help us better plan for your childs
assessment.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Do you have any particular question you would like to ask?

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Name of person completing this form: ______________________________________________

Relationship to child: _____________________________
Signature: ______________________________________
Date: __________________________________________

Children First School

SPECIAL EDUCATION PROGRAM

FORM 6a- PUPILS PERFORMANCE IN SCHOOL-BASED ACHIEVEMENT TESTS (SBAT)

Direction:
1. using the childs records