Please help us get to know your child by filling out this form. All the information will be confidential. We will use what you tell us as we begin to get to know your child and p l a n wa y s t o m eet hi s / h er n e e d s and t o h e l p h i m /h er develop. Please return it to school as soon as possible. Thanks so much! Childs Name Childs Nickname Parents’ Names Date
Date Format: MM slash DD slash YYYY
Child’s Teacher Does your child live with? Please Specify Please list the names and ages of others who live in your home. (This will help me write names correctly on pictures your child draws about his/her family.) Pets (Name & type of animal) Father’s Occupation Mother's Occupation Does your child have a room of his own? If not, with whom does he/she share a room? What are your child’s favourite play activities and interests? Does child use special words to go to the bathroom? Child’s favorite TV programs Hours per day spent watching TV Does your child usually play Does child have decided fears? If so, what? What responsibilities does your child have at home? What is your biggest discipline problem? What is your child’s favorite story or type of story or book? Did your child have a premature or difficult birth that may indicate cognitive delays? Is English the primary language spoken in the home? If not, what is? Does your child speak any English? Understand English? How does your child feel about coming to school? What do you hope your child will learn this year? Please make comments about anything else you think I need to know about your child It is our goal to encourage a sense of belongingness, promote an appreciation of others and enrich children’s experiences by integrating into our curriculum activities and information that reflect our individual children’s background. One way we can do this is by learning about each child’s family background, celebrated holidays, and traditions. Please take a few minutes to share with us your special family days or activities and how they are carried out in your home. What languages other than English are spoken by family members around your child? Does your child have any physical or learning disabilities? If so, please describe Are there any family members with disabilities that may directly impact your child’s daily life (for example, a deaf grandparent, wheelchair bound parent, etc.)? What information about your family’s background and culture would you like to share with us? What are the holidays, special days, or traditions your family partakes in? Are there any special foods, songs, items or symbols you include in your celebration of special family times? Does your child have any dietary restrictions due to allergies, intolerances, family or religious preferences? If yes, what is restricted? Are there any activities from your family’s culture or traditions that you would like to share with your child’s classroom? Are there any activities from your family’s culture or traditions that you would like to share with your child’s classroom? Please make comments about anything else you think I need to know about your child What are their strengths? What are the areas of weakness? What would you love for your child to get better at? My child learns best when the teacher is…. My child does not work well with… What is the best way to motivate your child? What are you looking forward to at YMIM? How would you like to be involved with your child’s education? What is your preferred method of communication (email, phone call, meeting, note…)___ Date ASQ Completed: Child’s date of birth:
Date Format: MM slash DD slash YYYY
Child's Gender Person filling out Questionnaire First Name Middle Initial Last name Street Relationship to child: Relationship to child: City : State / Province: Zip / Postal Code: Country Home telephone number: Other telephone number: Email Address Name of the people assisting in questionnaire completion: Program Information Child ID # Program ID # Program Name Important Points to Remember:
Try each activity with your child before marking a response.
Make completing this questionnaire a game that is fun for you and your child.
Make sure your child is not tired or hungry.
Please return this questionnaire by ________________________ Notes 1. Does your child tell you at least two things about common objects? For example, if you say to you chid, “ tell me about your bal. “ does se say something like, “Its’ round. It’s round. I throw it. Its’s big” 2. Does your child use all of the words in a sentence ( for example, “ a, ” “the”,”am,” ”is” and “ are ”) to make complete sentences, such as “ I am going to the park,” “Is there a top to play with?” Or “ Are you coming, too?” 3. Does your child use endings of words, such as “-s," "-ed,” and “-ing"? For example, does your child say things like, “I see two cats,” “lam playing,” or “I kicked the ball”? 4. Without giving your child help by pointing or repeating directions, does he follow three directions that are unrelated to one another? Give all three directions before your child starts. For example, you may ask your child, “Clap your hands, walk to the door, and sit down,” or "Give me the pen, open the book, and stand up. 5. Does your child use four- and five-word sentences? For example, does your child say, ”! want the car”? Please write an example: 6. When talking about something that already happened, does your child use words that end in “-ed,” such as “walked,” “jumped,” or “played”? Ask your child questions, such as “How did you get to the store?” (“We walked.”) “What did you do at your friend‘’s house?” (“We played.”) Please write an example: Communication Total Gross Motors 1. Does your child hop up and down on either the right foot or the left foot at least one time without losing her balance or falling? 2. While standing, does your child throw a ball overhand in the direction of a person standing at least 6 feet away? To throw _t overhand, your child must raise his arm to shoulder height and throw the ball forward. (Dropping the ball or throwing the ball underhand should be scored as “not yet.) 3. Does your child jump forward a distance of 20 inches from a standing position, starting with her feet together? 4. Does your child catch a large ball with both hands? should stand about 5 feet away and give your child two or ant three tries before you mark the answer. 5. Without holding onto anything, does your child stand on one foot for at least 5 seconds without losing her balance and putting her foot down? (You may give your child two or ' three tries before you mark the answer.) 6. Does your child walk on his tiptoes for 15 feet (about the length of a large car)? (You may show him how to do this.) Gross Motor Total Fine Motor 1. Using the shapes below to look at, does your child copy at least three shapes onto a large piece of paper using a pencil, crayon, or pen, with- out tracing? (Your child’s drawings should look similar to the design of the shapes below, but they may be different in size.) 2. Does your child unbutton one or more buttons? (Your child may use his own clothing or a doll’s clothing.) 3. Does your child color mostly within the lines in a coloring book or within the lines of a 2-inch circle that you draw? (Your child should not go more than 1/4 inch outside the lines on most of the picture.) 4. Ask your child to trace on the line below with a pencil. Does your child trace on the line without going off the line more than two times? (Mark “sometimes” if your child goes off the line three times.) 5. Ask your child to draw a picture of a person on a blank sheet of paper. You may ask your child, “Draw a picture of a girl or a boy.” If your child draws a person with head, body, arms, and legs, mark “yes.” If your child draws a person with only three parts (head, body, arms, or legs), mark “sometimes.” If your child draws a person with two or fewer parts (head, body, arms, or legs), mark “not yet.” Be sure to include the sheet of paper with your child’s drawing with this questionnaire. 6. Draw a line across a piece of paper. Using child-safe Um i scissors does your child cut the paper in half on more or less straight line, making the blades group _ and down? (Carefully watch your child's use of scissors for safety reasons.) Fine Motor Total Problem Solving 1. When shown objects and asked, “What color is this?” does your child name five different colors, like red, blue, yellow, orange, black, white, or pink? (Mark “yes” only if your child answers the question correctly using five colors.) 2. Does your child dress up and “play-act,” pretending to be someone or something else? For example, your child may dress up in different clothes and pretend to be a mommy, daddy, brother, sister, or an imaginary animal or figure. 3. If you place five objects in front of your child, can she count them by saying, “One, two, three, four, five” in order? (Ask this question without providing help by pointing, gesturing, or naming.) 4. When asked, “Which circle is smallest?” does your child point to the ) a smallest circle? (Ask this question without providing help by pointing, gesturing, or looking at the smallest circle.) 5. Does you child count up to 15 without making mistakes? If so, mark “yes” If your child counts to 12 without making mistakes, ,ark “some-times.” 6. Does your child know the names of numbers? (Mark “yes” if he identifies the three numbers below. Mark “sometimes” if he identifies two numbers.) Problem Solving Total Personal Social 1. Does your child wash her hands using soap and water and dry off withna towel without help? 1. Does your child wash her hands using soap and water and dry off withna towel without help? 2. Does your child tell you the names of two or more playmates, not including brothers and sisters? (Ask this question without providing help by suggesting names of playmates or friends.) 3. Does your child brush his teeth by putting toothpaste on the toothbrush and brushing all of his teeth without help? (You may still need to check and re brush your child's teeth.) 4. Does your child serve herself, taking food from one container to another, using utensils? (For example, does your child use a large spoon to scoop applesauce from a jar into a bowl?) 5. Does your child tell you at least four of the following? Please mark the items your child knows. 6. Does your child dress or undress himself without help (except for snaps, buttons, and zippers)? Personal Social Total 1. Do you think your child hears well? If no, explain: 2. Do you think your child talks like other children her age? If no explain 3. Can you understand most of water what your child says? If no, explain 4. Can other people understand most of what your child says?If no, explain 5. Do you think your child walks, runs, and climbs like other children his age? If no, explain: 6. Does either parent have a family history of childhood deafness or hearing impairment? If yes, explain: 7. Do you have any concerns about your child’s vision? If yes, explain: 8. Has your child had any medical problems in the last several months? If yes, explain: 9. Do you have any concerns about your child’s behavior? If yes, explain:
10. Does anything about your child worry you? If yes, explain: