Behavior Checklist
Student’s Name: ____________________________________ Date: ______________________________
Person Assessing: ___________________________________ Position: ___________________________
School: ___________________________________________
Social/Emotional Yes No Physical Yes No
Extremely Active Multiple health problems
Extremely lethargic Clumsy
Easily Distracted Fine motor difficulties
Short attention span Gross motor difficulties
Easily overstimulated Difficulty with vision processing
Difficulty calming/comforting self Difficulty with auditory processing
Impulsive Small/thin
Poor judgment Poor vision
Low tolerance for change Poor hearing
Problems with transitions Unclear speech pattern
Extremely persistent Little eye contact
Resists environmental change
Low tolerance for frustration
Stealing Classroom Performance Yes No
Lying Short term memory problems
Cheating Inconsistent mastery of skills
Difficulty with fantasy/reality Swiss cheese retention
Overactive fantasy life Need repetition
Stubborn, willful Poor integration of new skills
Sullen Difficulty staying on task
Defiant Exceptional long term memory
Emotionally volatile Need considerably more time for tasks
Inability to consider consequences Loses things easily
Poor communication skills Inconsistent with returning homework
Difficulty understanding feelings Difficulty following directions
Makes inappropriate noises Difficulty changing tasks
Able to parrot instructions – can’t Difficulty completing tasks
follow through Unable to follow multi-step directions
Intrudes into other’s business Inconsistent performance
Highly tactile Poor generalization
Aggressive Poor sequencing
Relates better to younger children Poor spatial orientation
Difficulty remembering social rules Unable to see patterns
Easily influenced by others Poor organizational skills
Tries hard to please Difficulty predicting outcomes
Lacks stranger intuition Difficulty in problem solving
Socially engaging Doesn’t learn from mistakes
Interested in others Processing delays
Affectionate Difficulty with verbal
Loyal directions/information
Makes friends easily Difficulty expressing knowledge
Happy, friendly Poor reading comprehension
Willing Better with hands-on lessons
Trusting Poor math concepts
Spontaneous, energetic Poor concept of time
People oriented Poor concept of money
Difficulty keeping friends Poor abstract reasoning
Copyright 2008, Sally Irons, [Link].
Permission granted to duplicate for educational purposes only.
Behavior Checklist
Student’s Name: ____________________________________ Date: ______________________________
Person Assessing: ___________________________________ Position: ___________________________
School: ___________________________________________
Learns best if… Yes No
Tasks are done in small segments Relevant Comments:
Information is given one item at a time
Verbal cues are given before
something changes
Reminders are frequent
Repetition is constant and consistent
Information is written as well
as verbal
Many of the senses can be involved
Use of manipulatives follows
instruction
Information uses art, music, etc.
Responds well to… Yes No
Structure
Routine
Consistency
Clear Limits
Few rules
Rules written and posted
“Time Out” place
Stability
Praise
Rewards
One-on-one explanation/tutoring
Copyright 2008, Sally Irons, [Link].
Permission granted to duplicate for educational purposes only.
