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Child’s name:________________________
Assessment period:________________________
Family Member:________________________
Date of Conversation:________/________/________
If confident with existing documentation (including your and other’s observations) indicate a rating. If more information/documentation is needed to rate the measure, fill in the other columns for that measure.
Measures on the
Approaches to Learning–Self-Regulation (ATL-REG) |
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List family and child |
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List questions or prompts to ask the family or |
Keep notes from conversation |
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1. Attention Maintenance Child develops the capacity to pay attention to people, things, or the environment when interacting with others or exploring play materials |
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3. Imitation |
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5. Self-Control of Feelings and Behavior |
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Measures on the
Social and Emotional Development (SED) |
Indicate |
List family and child |
Indicate |
List questions or prompts to ask the family or |
Keep notes from conversation |
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1. Identity of Self in Relation to Others |
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2. Social and Emotional Understanding |
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3. Relationships and Social Interactions with Familiar Adults Child develops close relationships with one or more familiar adults (including family members) and interacts in an increasingly competent and cooperative manner with familiar adults |
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4. Relationships and Social Interactions with Peers Child becomes increasingly competent and cooperative in interactions with peers and develops friendships with several peers |
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Measures on the
Language and Literacy Development (LLD) |
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List family and child |
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List questions or prompts to ask the family or |
Keep notes from conversation |
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1. Understanding of Language (Receptive) Child understands increasingly complex communication and language |
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3. Communication and Use of Language (Expressive) Child’s communication develops from nonverbal communication to using language with increasingly complex words and sentences |
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4. Reciprocal Communication and Conversation Child engages in back-and-forth communication that develops into increasingly extended conversations |
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5. Interest in Literacy |
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Measures on the
Cognition, Including Math and Science (COG) |
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List family and child |
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List questions or prompts to ask the family or |
Keep notes from conversation |
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1. Spatial Relationships |
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2. Classification |
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3. Number Sense of Quantity |
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8. Cause and Effect |
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9. Inquiry Through Observation and Investigation Child observes, explores, and investigates objects (living and nonliving things) and events in the environment and becomes increasingly sophisticated in pursuing knowledge about them |
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Measures on the
Physical Development–Health (PD-HLTH) |
Indicate |
List family and child |
Indicate |
List questions or prompts to ask the family or |
Keep notes from conversation |
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2. Gross Locomotor Movement Skills |
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4. Fine Motor Manipulative Skills Child demonstrates increasing precision, strength, coordination, and efficiency when using muscles of the hand for play and functional tasks |
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5. Safety |
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6. Personal Care Routines: Hygiene |
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