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3-5 yr old Self-Help and Social-Emotional Scales
Directions: Read each item and select the response or description that best reflects your child’s behavior or skill level.
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* Indicates required question
Your child's first name?
*
Your answer
SELF-HELP SKILLS
A. Eating Skills
1. Does your child use a spoon?
If yes, does your child place the spoon in his/her mouth without turning the spoon upside down and without spilling a lot of food?
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Rarely/No
Sometimes
Most of the time
2. Does your child use the side of the fork for cutting soft food, such as a piece of baked potato or a piece of cake?
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Rarely/No
Sometimes
Most of the time
3. Does your child hold a fork in his/her fingers, not in his/her fist?
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Rarely/No
Sometimes
Most of the time
SELF-HELP SKILLS
A. Dressing Skills
4. Does your child put on his/her shoes?
Criteria:
Buckling, tying, or Velcro® fastening is not required
for credit.
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No
Yes (sometimes on wrong feet)
Yes (each shoe on correct foot 90% of the time)
5. Does your child dress himself/herself unsupervised?
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Rarely/No
Sometimes
Most of the time, except for help with difficult fasteners
Yes (completely dresses himself/herself, putting all clothes on correctly and fastening all fasteners)
Yes (completely dresses himself/herself, including tying shoelaces and fastening all fasteners)
6. Does your child put on his/her socks?
*
Rarely/No
Sometimes
Most of the time
SELF-HELP SKILLS
A. Toileting Skills
7. Does your child get on the toilet or potty by himself/herself (even if he/she needs help with clothing)?
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Rarely/No
Sometimes
Most of the time
8. Does your child have bowel movements (“poop”) in the toilet or potty (no more than one accident a week)?
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Rarely/No
Sometimes
Most of the time
9. Does your child urinate (“pee”) in the toilet or potty (no more than one accident a week)?
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Rarely/No
Sometimes
Most of the time
10-a. Does your child
attempt
to wipe himself/herself after toileting? OR.. See question 10.b
Rarely/No
Sometimes
Most of the time
Clear selection
10-b. Does your child wipe himself/herself after toileting?
Rarely/No
Sometimes
Most of the time
Clear selection
11. Does your child take care of his/her toileting needs?
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Rarely/No
Sometimes
Yes (flushing the toilet most of the time after using it)
Yes (flushing the toilet and washing and drying his/her hands most of the time)
12. Does your child go to the bathroom on his/her own without being asked or reminded?
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Rarely/No
Sometimes
Most of the time
SOCIAL AND EMOTIONAL SKILLS
D. Relationship with Adults
13. Does your child respond with feelings of pride and enthusiasm when he/she earns positive feedback?
*
Rarely/No
Sometimes
Most of the time
14. Does your child look forward to sharing his/her feelings with you when he/she is happy?
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Rarely/No
Sometimes
Most of the time
15. Does your child enjoy sharing information with you about himself/herself, such as things he/she likes, names of his/her family members or pets, or what he/she did over the weekend?
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Rarely/No
Sometimes
Most of the time
16. Does your child share his/her thoughts and ideas with you?
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Rarely/No
Sometimes
Most of the time
SOCIAL AND EMOTIONAL SKILLS
E. Play and Relationships with Peers
17. Does your child have several friends but one who is a special or best friend?
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No
Yes
18. Does your child have a best friend with whom he/she is close and who reciprocates by coming over for play dates or extending an invitation to a party?
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No
Yes
19. Does your child play cooperatively in a large-group game, such as duck-duck-goose, tag, or kickball?
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Rarely/No
Sometimes
Often
20. Does your child give verbal directions or incorporate verbal directions into play activities?
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Rarely/No
Sometimes
Often
SOCIAL AND EMOTIONAL SKILLS
F. Motivation and Self-Confidence
21. Does your child maintain interest when engaged in a small-group activity or project?
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Rarely/No
Sometimes
Most of the time
22. Does your child show that he/she likes to finish what he/she starts, perhaps by dawdling less than at an earlier age?
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Rarely/No
Sometimes
Most of the time
23. Does your child approach new tasks with confidence and a “can-do” attitude?
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Rarely/No
Sometimes
Most of the time
24. Does your child remain focused on what he/she has been asked to do even when there are minor distractions, such as a car making noise outside or someone tapping a pencil?
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Rarely/No
Sometimes
Most of the time
SOCIAL AND EMOTIONAL SKILLS
G. Prosocial Skills and Behaviors
25. If supervised by an adult, does your child take turns without undue objection?
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Rarely/No
Sometimes
Most of the time
26. Does your child understand or accept the need to share and take turns, perhaps willingly taking turns even if he/she isn’t asked to?
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Rarely/No
Sometimes
Often
27. Does your child ask an adult for permission before using things that belong to others or before engaging in an activity that may be restricted, such as going to the bathroom or leaving the classroom?
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Rarely/No
Sometimes
Most of the time
28. Does your child react to a disappointment or failure in an acceptable
manner by being a good sport and refraining from shouting or
getting upset?
*
Rarely/No
Sometimes
Most of the time
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