Form Ssa-5665-Bk - Teacher Questionnaire Page 4
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10I. ACQUIRING AND USING INFORMATION
NO problems observed in this domain; functioning appears age-appropriate.
If you selected this block, go directly to Section II.
YES, the child has problems functioning in this domain.
Please mark a rating for each activity listed below.
RATING KEY FOR ACTIVITIES LISTED BELOW
impairments
Compared to the functioning of same-aged children without
, this child has:
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A slight problem
No Problem
An obvious problem
A serious problem
A very serious problem
RATING
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1. Comprehending oral instructions
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2. Understanding school and content vocabulary
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3. Reading and comprehending written material
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4. Comprehending and doing math problems
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5. Understanding and participating in class discussions
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6. Providing organized oral explanations and adequate descriptions
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7. Expressing ideas in written form
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8. Learning new material
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9. Recalling and applying previously learned material
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10. Applying problem-solving skills in class discussions
What else can you tell us about the child's problems with these activities? For example, how independent is the
child in doing them? Does the child get extra help, or an unusual degree of structure or support? If so, what kind
and how often? (Continue on the last page if needed.)
Form SSA-5665-BK (09-2011) ef (09-2011)
Page 2
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