Building Blocks Questionnaire

Student’s name: Grade:

Teacher’s name: Date:

PART 1
Use this questionnaire to provide an overview of the student’s school-related skills and behavior. The first 10 questions
are eneral. If you answer “Frequently” or “Sometimes” to any of the first 10 questions, proceed to Part 2 of the
questionnaire and complete the additional 10 items for that section. For example, if you answer “Frequently: to “Does
the student appear inattentive or impulsive?” then proceed to the first section of Part 2 and answer the additional 10
items about attention and self-regulation.

Rarely Sometimes Frequently

FOUNDATIONAL

1. Attention and Self regulation: Does the student appear

inattentive or impulsive?
Perhatian dan Pengaturan diri: Apakah siswa tampak lalai atau
impulsif?

2. Emotions: Does the student appear to be sad or anxious more

often than not during the day?
Emosi: Apakah siswa lebih sering terlihat sedih atau cemas
sepanjang hari?

3. Behavior: Does the student have trouble following school

rules?
Perilaku: Apakah siswa mengalami kesulitan mengikuti aturan
sekolah?

4. Self-Esteem: Does the student appear to have a low opinion of

him- or herself?
Harga diri: Apakah siswa tampak mempunyai opini rendah
terhadap dirinya sendiri?

SYMBOLIC

5. Phonological Processing: Does the student have difficulty

hearing or applying letter sounds when speaking, reading, or
spelling?
Proses Fonologis: Apakah siswa memiliki kesulitan mendengar
atau menerapkan bunyi huruf ketika berbicara, membaca, atau
mengeja?

6. Orthographic Processing: Does the student have trouble

reading or spelling words with irregular elements (e.g., once)?

7. Motor Processing: Does the student have difficulty forming

letters or writing legibly?
 CONCEPTUAL

8. Thinking with Language: Does the student have trouble using

or understanding oral language?

9. Thinking with Images: Does the student have difficulty

creating mental pictures?

10. Thinking with Strategies: Does the student have trouble

forming or following a plan?

PART 2
Complete the 10 items in each section corresponding with the items for which you answered “Frequently” or
“Sometimes” in Part 1.
FOUNDATIONAL

1.Attention and Self-Regulation

Rarely Sometimes Frequently

Appears restless and fidgety

Shows inconsistencies in behavior depending on the type of task

Has trouble staying seated

Seems to act before thinking

Fails to finish tasks

Has trouble making transitions

Has difficulty working independently

Has trouble persisting on routine tasks for extended periods of

time

Has difficulty listening to and following directions

Has trouble finding and organizing tasks and materials

2.Emotions

Rarely Sometimes Frequently

Appears to be sad
 Changes mood quickly

Worries excessively about school

Complains about school tasks

Cries

Seems anxious

Becomes angry quickly

Isolate self from peers

Seems bored or disinterested

Puts forth little effort

3.Behavior

Rarely Sometimes Frequently

Has difficulty getting along with peers

Is frequently in trouble at school

Lacks engagement in classroom instruction

Does not respond to discipline as expected

Disturbs or distracts others

Makes inappropriate physical contacts with peers (e.g., shoving,

pinching)

Insults other verbally

Refuses to comply when asked

Seems argumentative

Hurts self or others

4.Self-Esteem

Rarely Sometimes Frequently

Seems disinterested in academic tasks

Complains about not being smart

Complains that academic tasks are too difficult

 Has limited interactions with classmates

Complains about not being liked

Makes negative comments about self

Gives up easily on tasks and assignments

Seems overly sensitive to criticism

Criticizes others

Seems to lack self-confidence

SYMBOLIC

5.Phonological Processing

Rarely Sometimes Frequently

Has trouble rhyming words

Has difficulty pronouncing certain sounds

Has trouble putting sounds together to pronounce words

(blending) when reading

Has difficulty breaking sounds apart in words (segmenting)

when spelling

Has trouble distinguishing letters with similar sounds (e.g., /b/

and /p/, /f/ and /v/) in speech and when spelling

Has difficulty repeating information just heard

Has trouble learning the days of the week and months of the
year in sequence

Has difficulty connecting sounds to letters when spelling

Has trouble pronouncing multisyllabic words when speaking or

reading

Has difficulty pronouncing or spelling words with phonetically

regular patterns

6.Orthographic Processing

Rarely Sometimes Frequently

Forgets how letters look

Confuses letters with similar appearances (e.g., n for h)

 Misreads little words in text (e.g., were for where)

Reverses letters when spelling (e.g., b instead of d)

Transposes letters when reading or writing (e.g., on instead of

no)

Has trouble remembering basic sight words

Has difficulty copying from a book or chalkboard to paper

Spells the same word in different ways

Spells words the way they sound rather than the way they look

Reads at a slow rate

7.Motor Processing

Rarely Sometimes Frequently

Draws pictures that seem immature for age

Has difficulty with tasks involving fine motor coordination (e.g.,

tying shoes)

Seems disinterested in drawing or learning to write

Has trouble holding a crayon, pencil, or pen correctly

Forms letters in odd ways (e.g., starts from the nottom rather
than the top)

Has poor spacing between letters and words

Has papers that appear messy

Has poor or sloppy handwriting

Has difficulty learning cursive writing

Has a slow rate of writing

CONCEPTUAL

8. Thinking with Language

Rarely Sometimes Frequently

Was slow to develop and use oral language

Has trouble understanding directions or answering questions

 Has difficulty sustaining meaningful conversations

Makes grammatical errors when speaking

Has problems retrieving specific words

Has trouble understanding what is read

Has difficulty expressing ideas when writing

Has trouble summarizing or drawing conclusions

Has a limited speaking vocabulary

Has difficulty organizing and expressing ideas

9.Thinking with Images

Rarely Sometimes Frequently

Has trouble putting puzzles together

Has difficulty constructing models or designs

Has trouble solving math problems without counting on fingers

Has difficulty distinguishing left from right

Has trouble judging distances

Has difficulty solving math problems without using paper and

pencil

Has trouble with tasks involving spatial reasoning

Has difficulty using maps

Has trouble understanding diagrams or graphs

Has difficulty interpreting body language or social cues

10.Thinking with Strategies

Rarely Sometimes Frequently

Has trouble monitoring performance

Has difficulty identifying the steps of a task

Has trouble developing a plan to complete a task

Has difficulty sustaining effort when problem-solving

Has trouble identifying and prioritizing the most relevant aspects
of a task

Has difficulty revising or generating an alternative plan

Has trouble evaluating performance

Has difficulty selecting and using techniques to memorize

Has trouble selecting and using techniques to study

Has difficulty generalizing (i.e., talking what is learned in one

situation and applying it to another)