MODIFIED CHECKLIST FOR LSENs
Name: ____________________________________________________________________________
Learner’s Reference Number: __________________________________________________________
Birthdate: __________________________________________________________________________
Age: ______________________________________________________________________________
Address: __________________________________________________________________________
Grade: SPED
Assessment Report Legend:
BEGINNING (B) - Skill is present during evaluation but needs more improvement and
intervention
DEVELOPING (D) - Skill is exhibited in an acceptable manner
EMERGING (E) - Skill is instructional
SHOWS MASTERY (M) - Skill is independent
I. FUNCTIONAL ACADEMICS
To acquire basic skills in reading, writing and numeracy.
A. ENGLISH
GRADING Priority Based Program Rating
PERIOD 1st 2nd 3rd 4th
Identify letters of the alphabets
1st Quarter Recognize letter given in random
Can say name, age and gender
Recognize letter sounds
2nd Quarter Recognize names of familiar people and familiar body
parts
Speaks clearly enough for strangers to understand
Answers yes or no questions
3rd Quarter Associate words with pictures
Differentiate boys and girls
Understand the concepts of same and different
Identify all letters and produce its sounds
4th Quarter Recognize and identify all common objects and pictures
Understand is most of what is 75% of speech is
understandable
B. MATHMATICS
GRADING Priority Based Program Rating
PERIOD 1st 2nd 3rd 4th
Identify colors
1st Quarter Matches color with color name
Demonstrate number concepts of one to ten (Can select
one or two, can tell if one or two objects)
Draw correct shape
2nd Quarter Matches shape with shape name
Counts from 1 to 20
Identify numbers from 1 – 5, 1 – 10 and 1 – 20
3rd Quarter Can count 10 or more objects
Count by rote to 10, know what number comes next
Counts by rote
4 Quarter
th
Counts by set
II. COMMUNICATION SKILLS
The goal is implementing the communication skills program is on developing how well the child
understands and responds to the spoken language of others and how successfully he
communicates his needs, wants, feelings and thought to others.
GRADING Priority Based Program Rating
PERIOD 1st 2nd 3rd 4th
Names most common objects seen
1st Quarter Names objects that are heard
Names objects touched or handled
Names most pictures seen in books
2nd Quarter Defines 5 simple words by describing
Identifies / describes what he is doing
Identifies / describes action of familiar people
Identifies / describes action of other people
3rd Quarter Recognizes different colors
Recognizes different shapes
Recognize different shapes
4th Quarter Use prepositional concepts: on, under, next
Understand words like I, me, you, sit, stand, sleep,
walk, no, yes, play, listen, look, wait, come, etc.
III. AUDITORY LANGUAGE SKILLS
GRADING Priority Based Program Rating
PERIOD 1st 2nd 3rd 4th
Follow one – step instructions
1st Quarter Identifies body parts
Identifies objects
Identifies pictures
2nd Quarter Identifies familiar people
Follows verb instructions
Identifies verbs in pictures
3 Quarter
rd
Identifies objects in the environment
Points to pictures in a book
4th Quarter Identifies objects by function
Identifies possession
IV. SOCIAL SKILLS
GRADING Priority Based Program Rating
PERIOD 1st 2nd 3rd 4th
Waits for his turn in play sessions, school activity, etc.
1st Quarter Ability to take his turn in any activity
Has initiative to play with others
Ability to share objects, space, attention, information,
2nd Quarter etc.
Sustained eye-contact with others
Tolerates presence of others
Tolerates physical contact – hugs, kisses, tickles,
3rd Quarter handshakes, etc.
Remains in a new group or activity
Expresses feelings / emotions appropriately through
gestures or facial expressions
Plays cooperatively and interactively with 2 or more
4th Quarter sociable peers
Plays creatively and imaginatively
V. RECEPTIVE SKILLS
GRADING Priority Based Program Rating
PERIOD 1st 2nd 3rd 4th
Identifies rooms
st
1 Quarter Identifies emotions
Identifies places
2 Quarter
nd Follows two – step instructions
Identifies community helpers
rd
3 Quarter Follows directions with prepositions
Answers wh questions about objects and pictures
Answers yes / no in response to questions about objects
4 Quarter
th and actions
Names an objects by touch
VI. GROSS MOTOR SKILLS
GRADING Priority Based Program Rating
PERIOD 1st 2nd 3rd 4th
Jumps over an object with both feet
1st Quarter Walls forward independently
Climbs upstairs and goes downstairs using alternate well
nd
2 Quarter Skips well
Balances well within a given path
rd
3 Quarter Hops well
Handles balls and block with ease
4 Quarter
th Dribbles and catches a ball
Pushes and pulls objects without falling
VII. FINE MOTOR SKILLS
GRADING Priority Based Program Rating
PERIOD 1st 2nd 3rd 4th
Builds tower of 2nd stage of block building
1st Quarter String beads on thread or shoelace
Performs twisting activities efficiently
Fold paper / napkins with ease
2 Quarter
nd
Cuts straight / curved / jagged / around lines
Rolls up mats, paper or any item with similar materials
Tears paper with lines
3 Quarter
rd
Rolls balls
Puts small objects in a bottle
4 Quarter
th Handles pegs on board properly
Hold pencils, crayons and paint brush properly
VIII. SELF-HELP SKILLS
To acquire basic skills necessary for independent functioning.
GRADING Priority Based Program Rating
PERIOD 1st 2nd 3rd 4th
Drinks from a cup / glass
1st Quarter Drinks with a straw
Uses eating utensils properly
Feeding Clean spillage
Shows awareness about dirt and mess
Eats independently
Cleans and clears place and table
Cooperates when dressing / undressing
2nd Quarter Pulls off shoes
Pulls off socks
Dressing Ties shoes
Takes off pants / shorts
Takes off dress / skirt / blouse / shirt
Knows how to zip / unzip
Knows how to hook / unhook
Attempts to undress / dress independently
Washes hands with soap
3rd Quarter Washes face with soap
Knows how to use a wash cloth
Hygiene and Dries hands / face alone
Grooming Combs / brushes hair properly
Brushes teeth regularly
Blows nose on command
Keeps nose clean with hanky or tissue
Ask permission when going to toilet
4th Quarter Uses toilet with help
Toileting Follow complete toileting, wiping, flushing, washing
hands
Desires independently toileting
