Form Ssa-5665-Bk - Teacher Questionnaire Page 8
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10V. CARING FOR HIMSELF OR HERSELF
NO problems observed in this domain; functioning appears age-appropriate.
If you selected this block, go directly to Section VI.
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
FREQUENCY OF PROBLEM
Monthly
Weekly
Daily
Hourly
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3
4
5
1. Handling frustration appropriately
Monthly
Weekly
Daily
Hourly
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2
3
4
5
2. Being patient when necessary
Monthly
Weekly
Daily
Hourly
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4
5
3. Taking care of personal hygiene
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5
Monthly
Weekly
Daily
Hourly
4. Caring for physical needs (e.g, dressing, eating)
Monthly
Weekly
Daily
Hourly
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3
4
5
Cooperating in, or being responsible for, taking needed
5.
medications
Using good judgement regarding personal safety
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Monthly
Weekly
Daily
Hourly
6.
and dangerous circumstances
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5
Monthly
Weekly
Daily
Hourly
7. Identifying and appropriately asserting emotional needs
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Monthly
Weekly
Daily
Hourly
Responding appropriately to changes in own mood
8.
(e.g, calming self)
Monthly
Weekly
Daily
Hourly
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5
Using appropriate coping skills to meet daily demands
9.
of school environment
Monthly
Weekly
Daily
Hourly
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5
10. Knowing when to ask for help
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? Is so,
what kind and how often? (Continue on the last page if needed.)
Form SSA-5665-BK (09-2011) ef (09-2011)
Page 6
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