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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) |
Indicate |
List family and child |
Indicate |
List questions or prompts to ask the family or |
Keep notes from conversation |
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1. Attention Maintenance |
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3. Imitation |
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5. Self-Control of Feelings and Behavior Child increasingly develops strategies for regulating feelings and behavior, becoming less reliant on adult guidance over time |
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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 |
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4. Relationships and Social Interactions with Peers |
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Measures on the
Language and Literacy Development (LLD) |
Indicate |
List family and child |
Indicate |
List questions or prompts to ask the family or |
Keep notes from conversation |
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1. Understanding of Language (Receptive) |
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3. Communication and Use of Language (Expressive) |
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4. Reciprocal Communication and Conversation |
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5. Interest in Literacy Child shows interest in books, songs, rhymes, stories, and other literacy activities in increasingly complex ways |
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6. Comprehension of Age-Appropriate Text Child develops capacity to understand details and ideas from age-appropriate text presented by adults |
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7. Concepts About Print Child shows an increasing understanding of the conventions and physical organization of print material and that print carries meaning |
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9. Letter and Word Knowledge Child shows increasing awareness of letters in the environment and their relationship to sound, including understanding that letters make up words |
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10. Emergent Writing |
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Measures on the
Cognition, Including Math and Science (COG) |
Indicate |
List family and child |
Indicate |
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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7. Shapes |
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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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