Form Ssa-5665-Bk - Teacher Questionnaire Page 6
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10III. INTERACTING AND RELATING WITH OTHERS
NO problems observed in this domain; functioning appears age-appropriate.
If you selected this block, go directly to Section IV.
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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5
A slight problem
No Problem
An obvious problem
A serious problem
A very serious problem
RATING
FREQUENCY OF PROBLEM
Monthly
Weekly
Daily
Hourly
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2
3
4
5
1. Playing cooperatively with other children
Monthly
Weekly
Daily
Hourly
1
2
3
4
5
2. Making and keeping friends
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5
Monthly
Weekly
Daily
Hourly
3. Seeking attention appropriately
Monthly
Weekly
Daily
Hourly
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2
3
4
5
4. Expressing anger appropriately
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3
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5
Monthly
Weekly
Daily
Hourly
5. Asking permission appropriately
Monthly
Weekly
Daily
Hourly
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5
6. Following rules (classroom, games, sports)
Monthly
Weekly
Daily
Hourly
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5
7. Respecting/obeying adults in authority
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5
Monthly
Weekly
Daily
Hourly
8. Relating experiences and telling stories
Monthly
Weekly
Daily
Hourly
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4
5
9. Using language appropriate to the situation and listener
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Monthly
Weekly
Daily
Hourly
Introducing and maintaining relevant and appropriate
10.
topics of conversation
Monthly
Weekly
Daily
Hourly
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5
11. Taking turns in a conversation
Monthly
Weekly
Daily
Hourly
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5
Interpreting meaning of facial expression, body
12.
language, hints, sarcasm
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5
Monthly
Weekly
Daily
Hourly
Using adequate vocabulary and grammar to express
13.
thoughts/ideas in general, everyday conversation
NO
YES
Has it been necessary to implement behavior modification strategies for the child?
If yes, please explain below (e.g., behavior plan, personal assistant, time-out, quiet room, removal from the
classroom, change of school placement, suspension, expulsion). Please be as detailed as possible.
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.)
INTERACTING AND RELATING WITH OTHERS continued on next page
Form SSA-5665-BK (09-2011) ef (09-2011)
Page 4
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