BRIGANCE® Screen 

III Foundation Data Sheet

E
Year Month Day
Date of
A. Child’s Name _______________________________________________ Screening ______ ______ ______ School/Program ______________________________________
Parent(s)/Caregiver(s) ________________________________________ Birth Date ______ ______ ______ Teacher _____________________________________________
Address ___________________________________________________ Age ______ ______ ______ Examiner ____________________________________________

L
B. Core Assessments C. Scoring
Directions: Assessments may be administered in any order. For each assessment, start with the first
first item and proceed in order.
Number Correct
Give credit for a skill by circling the item number. 1. Child’s
3 Point Value
Page Domain For a skill not demonstrated (an incorrect response), slash through the item number. 1. Discontinue for Each Score
1A Knows Personal Information

P
Stop after 3 incorrect
3 Academic/Cognitive
Knows: 1. first name 2. last name 3. age 4. birthday (month and day) 5. telephone number 6. street address rresponses
esponses in a row. ____ 3 1.5 ____ /9
2A Names Parts of the Body
____ / 6
Stop after 3 incorrect
Stop
5 Language Development ____ 3 1
Names: 1. thumbs 2. fingernails 3. chin 4. chest 5. elbows 6. shoulders responses in a row.
3A Gross Motor Skills
1. Stands on one foot for ten seconds 4. Stands on other foot for one second with eyes closed Stop after 3 skills not
6 Physical Development
2. Stands on other foot for ten seconds 5. Walks backward toe-to-heel four steps demonstrated in a row.
3. Stands on one foot for one second with eyes closed ____ 3 1 ____ /5
4A Visual Motor Skills
____ / 7.5
Stop after 3 skills not
8 Physical Development ____ 3 1.5
Draws: 1. an X 2. a square 3. a rectangle 4. a triangle 5. a diamond demonstrated in a row.

M
5A Prints Personal Information
10 Physical Development
Prints: 1. first name 2. last name
Administer both items. ____ 3 3 ____ / 6

6A Recites Alphabet (1 point per group)

12 Academic/Cognitive: Literacy
a b c d e f g h i j k l m n o p q r s t u v w x y z
Stop after the first error. ____ 3 1 ____ / 5
7A Sorts Objects (by Size, Colour, Shape)
13 Academic/Cognitive: Mathematics
Sorts by: 1. size and colour 2. size and shape
Administer both items. ____ 3 3 ____ / 6
8A Counts by Rote (3 points per group)
14 Academic/Cognitive: Mathematics Stop after the first error. /9

A
Counts to: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 ____ 3 3 ____

9A Matches Quantities with Numerals

____ /10
Stop after 2 incorrect
15 Academic/Cognitive: Mathematics ____ 3 2
Matches quantity with numeral for: 1. 2 2. 4 3. 3 4. 8 5. 6 responses in a row.
10A Determines Total of Two Sets
16 Academic/Cognitive: Mathematics Counts two groups of objects for a sum up to ten: Administer all items.
____ 3 3 ____ /9

S
1. 1 dot + 2 dots = 3 dots 2. 4 dots + 2 dots = 6 dots 3. 5 stars + 5 stars = 10 stars
11A Reads Uppercase Letters Give credit for only one Stop after 3 incorrect
17 assessment – Reads ____ 3 0.5
O A X E B S C Z D L R T M P W K F N H I Y G U V J Q responses in a row.
Academic/Cognitive: Literacy Uppercase Letters OR OR
11A Alternate – Reads Lowercase Letters Reads Lowercase Stop after 3 incorrect
18
o s x c z m p w e a i k y r t v n f h u j g l b d q Letters. responses in a row. ____ 3 0.5 ____ 13 /
12A Experience with Books and Text
19 Academic/Cognitive: Literacy 1. Knows the front and back of a book 3. Understands that text progresses from top to bottom Administer all items.
2. Understands that text progresses from left to right / 4.5
____ 3 1.5 ____

21 Language Development 13A Verbal Fluency and Articulation 1. Uses sentences of at least five words 2. At least 90% of speech is intelligible Administer both items. ____ 3 5 ____ /10

Total Score = ______ /100

D. Notes/Observations: E. Next Steps:

© 2014 Hawker Brownlow Education Brigance® Screen III Foundation Data Sheet • CA14315-S
MP160