PROBLEM CHECKLIST
Child's name: ______________________________
Date of observation: _________________________
Child's age: ________________________________
Does the child behave in any of the following ways on a daily basis?
Fidgets or squirms during circle or story time
Talks a great deal while engaged in other activities (such as an art project)
Interrupts frequently when the teacher is reading to the group
Has difficulty completing simple projects that most other children complete
Can't follow directions unless the teacher is supervising her or walking her through the task step by step (washing hands, putting toys away, getting item from cubby)
Blurts out answers to questions before the teacher has finished asking the question
Has difficulty waiting for a turn in group situations
Engages in dangerous activities without considering the consequences (running into street, jumping off a high slide)
Uses physical actions (grabbing, hitting) rather than words
Easily distracted when listening to a story
Looks up from activity when other children walk by
Has trouble following a sequence of more than one direction (such as "Take this book to the table, then come back here and sit down")
Wanders around classroom unless told what to do
Hits, pushes, or shoves other children without apparent cause
Are there any other comments you'd like to make about this child's behavior?
________________________________________
Problem Checklist
Put Check if the situation is occurred.
He/ She was crying
He/ She injured from his/her classmates
He/ She have damage on his/her head, arms, thigh, etc.
He/ She has bite marks and wounds
He/ She is often easily disturbed y extraneous stimuli
He/ She is often loses things necessary for tasks or activities such as toys, school assignment etc.
He/ She I can’t talk or speak well because he/she feels shame and afraid
He/ She is often spiteful by his/her classmates
He/ She is often loses one’s temper
He/ She was hitting, kicking, or threatening to his/her classmates
He/ She pushed his/her classmates.
He/ She don’t get his/her personal things, and then he/she spanked his/her
He/ She has bullying his/ her classmates
He/ She was biting his/her classmates
He/ she always aggressive
He/ She is always say bad words to his/ her Classmates
He/ She are often angry and resentful to his/her classmates.
He/ She blame other classmates for one’s mistakes or misbehavior.
FOR TEACHERS
He/ She asked each of the children regarding the problem
He/ She were shouting to his/her children.
He/ She ignored the problem situation
He/ She shocked in the situation
He/ She is angry and take the children outside the room
He/ She used force to stop the quarreling or fighting between two children
He/ She used activities to catch up their attention
He/ She hurt his/her children.
He/ She talked to the children about the situation
He/ she didn’t know what happened and what he/she can do
He/ She were crying.
PROBLEM CHECLIST
CHILD'S NAME: __________ __________ __________
First Middle Last
CHILD'S GENDER: _____Boy _____ Girl
CHILD'S AGE: _____(Years) ______(Months)
CHILD'S BIRTH DATE: _____ (Month) _____ (Day) _____(Year)
TODAY'S DATE: _____(Month) _____(Day) _____(Year)
Below is a list of items that describes children. For each item that describes th child now or within __________ (days, weeks, or months) please circle the 2, if the item is very true or often true of the child. Circle the 1 if the item is somewhat or sometimes true of the child. If the item is not true of the child, circle 0. Please answer all th items as well as you can, even if some do not seem to apply to the child.
0 = not true 1 = somewhat or sometimes true 2 = very true or often true
_________________________________________________________________________
0 1 2 1. Aches or pains (without medical cause; do not include stomach or headaches)
0 1 2 2. Acts too young for age
0 1 2 3. Afraid to try new things
0 1 2 4. Avoids looking others in the eye
0 1 2 5. Can’t concentrate, can’t pay attention for long
0 1 2 6. Can’t sit still, restless, or hyperactive
0 1 2 7. Can’t stand having things out of place
0 1 2 8. Can’t stand waiting; wants everything now
0 1 2 9. Chews on things that aren’t edible
0 1 2 10. Clings to adults or too dependent
0 1 2 12. Apathetic or unmotivated
0 1 2 13. Cries a lot
0 1 2 14. Cruel to animals
0 1 2 15. Defiant
0 1 2 16. Demands must be met immediately
0 1 2 17. Destroys his/her own things
0 1 2 18. Destroys property belonging to others
0 1 2 19. Daydreams or gets lost in his/her thoughts
0 1 2 20. Disobedient
0 1 2 21. Disturbed by any change in routine
0 1 2 22. Cruelty, bullying, or meanness to others
0 1 2 23. Doesn’t answer when people talk to him/her
0 1 2 24. Difficulty following directions
0 1 2 25. Doesn’t get along with other children
0 1 2 26. Doesn’t know how to have fun; acts like a little adult
0 1 2 27. Doesn’t seem to feel guilty after misbehaving
0 1 2 28. Disturbs other children
0 1 2 29. Easily frustrated
0 1 2 30. Easily jealous
0 1 2 31. Eats or drinks things that are not food—do not include sweets (describe): _______________
____________________________________
0 1 2 32. Fears certain animals, situations, or places other than daycare or school (describe):
____________________________________
____________________________________
0 1 2 33. Feelings are easily hurt
0 1 2 34. Gets hurt a lot, accident-prone
0 1 2 35. Gets in many fights
0 1 2 36. Gets into everything
0 1 2 37. Gets too upset when separated from parents
0 1 2 38. Explosive and unpredictable behavior
0 1 2 39. Headaches (without medical cause)
0 1 2 40. Hits others
0 1 2 41. Holds his/her breath
0 1 2 42. Hurts animals or people without meaning to
0 1 2 43. Looks unhappy without good reason
0 1 2 44. Angry moods
0 1 2 45. Nausea, feels sick (without medical cause)
0 1 2 46. Nervous movements or twitching (describe): ______________________________________
______________________________________
0 1 2 47. Nervous, highstrung, or tense
0 1 2 48. Fails to carry out assigned tasks
0 1 2 49. Fears daycare or school
0 1 2 50. Overtired
0 1 2 51. Fidgets
0 1 2 52. Gets teased by other children
0 1 2 53. Physically attacks people
0 1 2 54. Picks nose, skin, or other parts of body (describe): _____________________________
______________________________________
0 1 2 55. Plays with own sex parts too much
0 1 2 56. Poorly coordinated or clumsy
0 1 2 57. Problems with eyes without medical cause (describe): _____________________________
_____________________________________
0 1 2 58. Punishment doesn’t change his/her behavior
0 1 2 59. Quickly shifts from one activity to another
0 1 2 60. Rashes or other skin problems (without medical cause)
0 1 2 61. Refuses to eat
0 1 2 62. Refuses to play active games
0 1 2 63. Repeatedly rocks head or body
0 1 2 64. Inattentive, easily distracted
0 1 2 65. Lying or cheating
0 1 2 66. Screams a lot
0 1 2 67. Seems unresponsive to affection
0 1 2 68. Self-conscious or easily embarrassed
0 1 2 69. Selfish or won’t share
0 1 2 70. Shows little affection toward people
0 1 2 71. Shows little interest in things around him/her
0 1 2 72. Shows too little fear of getting hurt
0 1 2 73. Too shy or timid
0 1 2 74. Not liked by other children
0 1 2 75. Overactive
0 1 2 76. Speech problem (describe): ________________
______________________________________
0 1 2 77. Stares into space or seems preoccupied
0 1 2 78. Stomachaches or cramps (without medical cause)
0 1 2 79. Overconforms to rules
0 1 2 80. Strange behavior (describe): ________________
______________________________________
0 1 2 81. Stubborn, sullen, or irritable
0 1 2 82. Sudden changes in mood or feelings
0 1 2 83. Sulks a lot
0 1 2 84. Teases a lot
0 1 2 85. Temper tantrums or hot temper
0 1 2 86. Too concerned with neatness or cleanliness
0 1 2 87. Too fearful or anxious
0 1 2 88. Uncooperative
0 1 2 89. Underactive, slow moving, or lacks energy
0 1 2 90. Unhappy, sad, or depressed
0 1 2 91. Unusually loud
0 1 2 92. Upset by new people or situations (describe): ______________________________
______________________________________
0 1 2 93. Vomiting, throwing up (without medical cause)
0 1 2 94. Unclean personal appearance
0 1 2 95. Wanders away
0 1 2 96. Wants a lot of attention
0 1 2 97. Whining
0 1 2 98. Withdrawn, doesn’t get involved with others
0 1 2 99. Worries
100. Please write in any problems the child has that were not listed above.
0 1 2 ______________________________________
0 1 2 ______________________________________
0 1 2 ______________________________________
Please be sure you have answered all items.
Underline any you are concerned about.
_________________________________________________________________________
Does the child have any illness or disability (either physical or mental)? ___No ___Yes-Please Describe
______________________________________________________________________________________________
What concerns you most about the child?
_________________________________________________________________________
Please describe the best things about the child:
_________________________________________________________________________
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