Form Ssa-5665-Bk - Teacher Questionnaire Page 7
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10III. INTERACTING AND RELATING WITH OTHERS (CONTINUED)
How much of the child's speech can you, as a familiar
Very Little
1/2 to 2/3
Almost
No more
listener, understand on the first attempt?
All
than 1/2
1. When the topic of conversation is known?
2. When the topic of conversation is unknown?
How much of the child's speech can you, as a familiar listener,
understand after repetition and/or rephrasing?
IV. MOVING ABOUT AND MANIPULATING OBJECTS
NO problems observed in this domain; functioning appears age-appropriate.
If you selected this block, go directly to Section V.
YES, the child has problems functioning in this domain.
Please mark a rating for each activity listed below.
RATING KEY FOR ACTIVITIES LISTED BELOW
Compared to the functioning of same-aged children without impairments, this child has:
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1
3
4
5
A slight problem
No Problem
An obvious problem
A serious problem
A very serious problem
RATING
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2
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4
5
Moving body from one place to another (e.g., standing, balancing, shifting weight,
1.
bending, kneeling, crouching, walking, running, jumping, climbing)
1
2
3
4
5
Moving and manipulating things (e.g., pushing, pulling, lifting, carrying,
2.
transferring objects; coordinating eyes and hands to manipulate small objects)
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2
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4
5
3. Demonstrating strength, coordination, dexterity in activities or tasks
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4
5
4. Managing pace of physical activities or tasks
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4
5
5. Showing a sense of body's location and movement in space
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5
6. Integrating sensory input with motor output
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7. Planning, remembering, executing controlled motor movements
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 5
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