PRESCHOOL FUNCTIONAL EDUCATION CHECKLIST
Student Date of Birth
School Teacher
Preschool Attendance: AM PM (circle one) Student Age
Therapist/Person Completing Form
Date of Form Completion
I. Areas of Concern
Fine Motor Gross Motor
Self-Care Sensory-Motor
II. Areas of Qualification (Check the specific areas in which the child initially qualified as a preschooler with a
disability)
Adaptive Behavior Cognitive Ability
Communication Gross/Fine Motor
Hearing Ability Pre-academic Skills
Social/Emotional/Behavioral Vision Ability
III. Specific Concerns (Please complete sections in specific areas of concern)
A. Hand Use/Fine Motor (please mark “Y” for yes or “N” for no)
1. Does the child use a preferred hand? Which one?
2a. Is the child able to isolate the index finger to point?
2b. Is the child able to push down and activate a toy using the index finger?
3a. When an object is placed in the child’s hand, will the child grasp the object?
3b. When an object is presented, does the child pick it up and hold it?
4. When the child picks up small objects, which of the following grasps are observed? (Please check)
____ Raking grasp (uses all fingers to rake objects into palm)
st nd
____ 3-finger grasp (grasp object with thumb and 1 and 2 fingers)
____ 2-finger grasp (grasp object with thumb and index finger)
5. Is the child able to release an object into a designated area?
6. What is the smallest item the child is able to release (e.g., stuffed animal, block, cereal)?
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7. Is the child able to bring his/her hands together to play with an object or to clap?
8. When holding an object, will the child transfer it to the opposite hand?
9. Does the child use one hand to hold or stabilize an object while performing a task with the other hand (e.g.,
stirring, stringing beads, playing musical instruments, putting notebook into book bag, holding paper
while cutting or writing)?
B. Tool Use (please mark “Y” for yes or “N” for no)
1. Does the child use a fisted grasp when holding a writing utensil?
2. Does the child use a 3-finger grasp (grasp with thumb & pad of index finger w/ utensil resting against side
of middle finger)?
3. Does the child position scissors correctly in fingers?
C. Visual-Motor (please mark “Y” for yes or “N” for no)
1. Does the child visually attend to objects during interaction (e.g. cutting, prewriting tasks)?
2. Can the child complete a 3-shape form board?
3. Is the child able to copy the shapes listed below as commensurate with the child’s ages as stated on the
Test of Visual-Motor Integration (Beery, 1997)?
Shape Chronological Age Shape Chronological Age
___ ___ Vertical line 2-10 ___ ___ Square 4-6
___ ___ Horizontal line 3-0 ___ ___ Left diagonal line 4-7
___ ___ Circle 3-0 ___ ___ X 4-11
___ ___ Cross 4-1 ___ ___ Triangle 5-3
___ ___ Right diagonal line 4-4
4. When coloring: (Please include work sample)
___ The child makes random marks on the paper.
___ The child attempts to remain in defined area.
___ The child fills approximately ___ amount of the shape/area.
5a. Has printing students’ name been introduced in the classroom?
5b. Can the child independently trace the letters in his/her first name?
5c. Can the child independently print his/her name when given a model?
5d. Can the child independently print his/her name without a model?
6a. Can the child snip paper with scissors?
6b. Can the child cut a piece of 8 ½ x11” paper in half?
6c. Can the child cut on a straight line?
6d. Can the child cut out a circle?
6e. Can the child cut out a square?
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D. Self-Care/Adaptive Behavior (please mark “Y” for yes or “N” for no)
1. Is the child able to self-feed a variety of sizes of finger foods?
2. Is the child able to use a spoon to self-feed?
3. Can the child pour liquid from a pitcher without spilling?
4. Is the child able to drink from a regular cup without spilling?
5. Is the child able to place a cup on the table after drinking?
6. Is the child able to suck from a straw?
7. Is the child able to wash his/her hands? If “no” what steps can the child complete?
8. Is the child independent with toileting? If “no,” what steps can the child complete?
9. Is the child able to put on and take off a coat? What method is used for putting the coat on (e.g.,
traditional method or flipover method)?
10. Is the child able to thread the zipper on a jacket and pull the zipper up and down?
11. Is the child able to put on and take off and open and close a book bag?
12. Is the child able to hang up a coat and book bag on a hook?
13. Can the child put shoes on the correct feet?
E. Gross Motor (please mark “Y” for yes or “N” for no)
1. Is the child able to sit and stand independently and unsupported?
2a. Can the child stand on one foot?
2b. Can the child jump up, clearing both feet off of the ground?
2c. Can the child hop on one foot?
3. Describe how the child walks up and down stairs:
4. Is the child able to keep up with peers when (please check):
___ Walking down the hall in line? ___ Walking up and down stairs?
5. Is the child able to run?
6. Is the child able to get on and off a riding toy?
7. Is the child able to pedal a tricycle?
8a. Can the child get in and out of a small chair?
8b. Can the child push a chair toward and from the table?
9. Can the child get up from and down onto the floor?
10. Can the child manage self on different terrains (e.g., grass, gravel, carpet, going up a hill)?
11. Can the child navigate around and over objects on the floor?
12. Can the child maintain balance when challenged?
13. Does the child trip or fall easily?
14. Can the child access playground equipment that is appropriate for his/her size?
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E. Sensory-Motor (please mark “Y” for yes or “N” for no)
--Tactile
1. Can the child tolerate others in his or her personal space (e.g., during circle time, in line, free play)?
2. Can the child tolerate a variety of textures on his/her hands (e.g., glue, finger paint, shaving cream, sand)?
3. Does the child appear irritated by certain clothing textures (e.g., does the child itch/push-up sleeves)?
4. Does the child resist having his/her face or hands washed?
5. Does the child have specific and/or limited food preferences?
--Vestibular
6. Does the child resist utilizing playground equipment? What type?
7. Does the child appear fearful or cautious with movement (e.g., on steps, when climbing or walking)?
--Proprioceptive
8. Is the child clumsy or awkward?
9. Does the child display self-abusive or self-stimulatory behaviors (e.g., hitting self, head banging)? Describe:
10. Does the child bump into objects?
11. Is the child a messy eater?
--Auditory
12. Does the child appear sensitive to sounds (e.g., loud toys, other children talking, school bell, fire alarms)?
13. What does the child do to demonstrate that s/he is sensitive to sounds (e.g. cover ears)? Describe:
F. Miscellaneous
1. Is the child able to follow 2-3 step directions?
2. Does the child display a high level of activity?
3. Is the child able to maintain the attention needed to complete a task?
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