Form Ssa-5665-Bk - Teacher Questionnaire Page 5
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10II. ATTENDING AND COMPLETING TASKS
NO problems observed in this domain; functioning appears age-appropriate.
If you selected this block, go directly to Section III.
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 very serious problem
A serious problem
RATING
FREQUENCY OF PROBLEM
Monthly
Weekly
Daily
Hourly
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2
3
4
5
1. Paying attention when spoken to directly
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3
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5
Monthly
Weekly
Daily
Hourly
2. Sustaining attention during play/sports activities
Monthly
Weekly
Daily
Hourly
1
2
3
4
5
3. Focusing long enough to finish assigned activity or task
Monthly
Weekly
Daily
Hourly
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2
3
4
5
4. Refocusing to task when necessary
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2
3
4
5
Monthly
Weekly
Daily
Hourly
5. Carrying out single-step instructions
Monthly
Weekly
Daily
Hourly
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2
3
4
5
6. Carrying out multi-step instructions
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5
Monthly
Weekly
Daily
Hourly
7. Waiting to take turns
Monthly
Weekly
Daily
Hourly
1
2
3
4
5
Changing from one activity to another without being
8.
disruptive
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2
3
4
5
Monthly
Weekly
Daily
Hourly
9. Organizing own things or school materials
Monthly
Weekly
Daily
Hourly
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4
5
10. Completing class/homework assignments
Monthly
Weekly
Daily
Hourly
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3
4
5
11. Completing work accurately without careless mistakes
Monthly
Weekly
Daily
Hourly
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5
12. Working without distracting self or others
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5
Monthly
Weekly
Daily
Hourly
13. Working at reasonable pace/finishing on time
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 3
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