Functional Life Skills - Elementary School 2019-2020

Functional Living Skills

Please complete this 2 page survey in its entirety

Students should be able to independently perform these skills by the end of 4th grade

Instructions: Please rate your child on each task according to the rating scale below. Click the response that most closely describes your child's ability.

1 - Unable to Perform Task

2 - Performs Task with prompting and/or support

3 - Performs task independently

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* 1. Student Information

Name

Parent Email Address

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* 2. Gender

Male

Female

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* 3. Social Skills

	Unable to perform task	Performs task with prompting and/or support	Performs task independently
Demonstrates basic understanding of Social Decision Making and Social Thinking skills	Demonstrates basic understanding of Social Decision Making and Social Thinking skills Unable to perform task	Demonstrates basic understanding of Social Decision Making and Social Thinking skills Performs task with prompting and/or support	Demonstrates basic understanding of Social Decision Making and Social Thinking skills Performs task independently
Demonstrates respect for adults	Demonstrates respect for adults Unable to perform task	Demonstrates respect for adults Performs task with prompting and/or support	Demonstrates respect for adults Performs task independently
Exhibits manners	Exhibits manners Unable to perform task	Exhibits manners Performs task with prompting and/or support	Exhibits manners Performs task independently
Follows directions	Follows directions Unable to perform task	Follows directions Performs task with prompting and/or support	Follows directions Performs task independently
Shares belongings	Shares belongings Unable to perform task	Shares belongings Performs task with prompting and/or support	Shares belongings Performs task independently
Takes turns	Takes turns Unable to perform task	Takes turns Performs task with prompting and/or support	Takes turns Performs task independently
Uses Active Listening	Uses Active Listening Unable to perform task	Uses Active Listening Performs task with prompting and/or support	Uses Active Listening Performs task independently

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* 4. Comments

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* 5. Personal Grooming

	Unable to perform task	Performs task with prompting and/or support	Performs task independently
Brushes teeth	Brushes teeth Unable to perform task	Brushes teeth Performs task with prompting and/or support	Brushes teeth Performs task independently
Brushes / combs hair	Brushes / combs hair Unable to perform task	Brushes / combs hair Performs task with prompting and/or support	Brushes / combs hair Performs task independently
Buttons pants / shirts	Buttons pants / shirts Unable to perform task	Buttons pants / shirts Performs task with prompting and/or support	Buttons pants / shirts Performs task independently
Dresses self	Dresses self Unable to perform task	Dresses self Performs task with prompting and/or support	Dresses self Performs task independently
Picks out clean clothes that are appropriate to the setting	Picks out clean clothes that are appropriate to the setting Unable to perform task	Picks out clean clothes that are appropriate to the setting Performs task with prompting and/or support	Picks out clean clothes that are appropriate to the setting Performs task independently
Puts on and ties shoes correctly	Puts on and ties shoes correctly Unable to perform task	Puts on and ties shoes correctly Performs task with prompting and/or support	Puts on and ties shoes correctly Performs task independently
Showers / bathes	Showers / bathes Unable to perform task	Showers / bathes Performs task with prompting and/or support	Showers / bathes Performs task independently
Washes hands after using the bathroom / before eating	Washes hands after using the bathroom / before eating Unable to perform task	Washes hands after using the bathroom / before eating Performs task with prompting and/or support	Washes hands after using the bathroom / before eating Performs task independently
Zips jacket	Zips jacket Unable to perform task	Zips jacket Performs task with prompting and/or support	Zips jacket Performs task independently

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* 6. Comments

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* 7. Household Tasks

	Unable to perform task	Performs task with prompting and/or support	Performs task independently
Assists in the kitchen (stirring, prep)	Assists in the kitchen (stirring, prep) Unable to perform task	Assists in the kitchen (stirring, prep) Performs task with prompting and/or support	Assists in the kitchen (stirring, prep) Performs task independently
Cleans up after self (toys, clothes)	Cleans up after self (toys, clothes) Unable to perform task	Cleans up after self (toys, clothes) Performs task with prompting and/or support	Cleans up after self (toys, clothes) Performs task independently
Clears table	Clears table Unable to perform task	Clears table Performs task with prompting and/or support	Clears table Performs task independently
Dusts	Dusts Unable to perform task	Dusts Performs task with prompting and/or support	Dusts Performs task independently
Empties trash baskets	Empties trash baskets Unable to perform task	Empties trash baskets Performs task with prompting and/or support	Empties trash baskets Performs task independently
Feeds pets	Feeds pets Unable to perform task	Feeds pets Performs task with prompting and/or support	Feeds pets Performs task independently
Makes bed	Makes bed Unable to perform task	Makes bed Performs task with prompting and/or support	Makes bed Performs task independently
Sets table	Sets table Unable to perform task	Sets table Performs task with prompting and/or support	Sets table Performs task independently
Sorts own clothes for laundry	Sorts own clothes for laundry Unable to perform task	Sorts own clothes for laundry Performs task with prompting and/or support	Sorts own clothes for laundry Performs task independently
Sorts recyclables	Sorts recyclables Unable to perform task	Sorts recyclables Performs task with prompting and/or support	Sorts recyclables Performs task independently
Sweeps and uses dustpan	Sweeps and uses dustpan Unable to perform task	Sweeps and uses dustpan Performs task with prompting and/or support	Sweeps and uses dustpan Performs task independently
Waters plants	Waters plants Unable to perform task	Waters plants Performs task with prompting and/or support	Waters plants Performs task independently

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* 8. Comments

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* 9. Food Management

	Unable to perform task	Performs task with prompting and/or support	Performs task independently
Cooks a basic meal (cereal, eggs, salad)	Cooks a basic meal (cereal, eggs, salad) Unable to perform task	Cooks a basic meal (cereal, eggs, salad) Performs task with prompting and/or support	Cooks a basic meal (cereal, eggs, salad) Performs task independently
Eats a variety of nutritious foods	Eats a variety of nutritious foods Unable to perform task	Eats a variety of nutritious foods Performs task with prompting and/or support	Eats a variety of nutritious foods Performs task independently
Identifies nutritious foods by reading labels	Identifies nutritious foods by reading labels Unable to perform task	Identifies nutritious foods by reading labels Performs task with prompting and/or support	Identifies nutritious foods by reading labels Performs task independently
Knows which foods require refrigeration	Knows which foods require refrigeration Unable to perform task	Knows which foods require refrigeration Performs task with prompting and/or support	Knows which foods require refrigeration Performs task independently
Orders a meal in a restaurant	Orders a meal in a restaurant Unable to perform task	Orders a meal in a restaurant Performs task with prompting and/or support	Orders a meal in a restaurant Performs task independently
Prepares a healthy snack	Prepares a healthy snack Unable to perform task	Prepares a healthy snack Performs task with prompting and/or support	Prepares a healthy snack Performs task independently
Prepares a sandwich	Prepares a sandwich Unable to perform task	Prepares a sandwich Performs task with prompting and/or support	Prepares a sandwich Performs task independently
Reads and understands a menu	Reads and understands a menu Unable to perform task	Reads and understands a menu Performs task with prompting and/or support	Reads and understands a menu Performs task independently
Uses a knife to cut food	Uses a knife to cut food Unable to perform task	Uses a knife to cut food Performs task with prompting and/or support	Uses a knife to cut food Performs task independently
Uses a knife to spread	Uses a knife to spread Unable to perform task	Uses a knife to spread Performs task with prompting and/or support	Uses a knife to spread Performs task independently
Uses the microwave safely	Uses the microwave safely Unable to perform task	Uses the microwave safely Performs task with prompting and/or support	Uses the microwave safely Performs task independently

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* 10. Comments

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* 11. Time Management

	Unable to perform task	Performs task with prompting and/or support	Performs task independently
Identifies hour hand	Identifies hour hand Unable to perform task	Identifies hour hand Performs task with prompting and/or support	Identifies hour hand Performs task independently
Identifies minute hand	Identifies minute hand Unable to perform task	Identifies minute hand Performs task with prompting and/or support	Identifies minute hand Performs task independently
Knows the number and the names of the months in a year	Knows the number and the names of the months in a year Unable to perform task	Knows the number and the names of the months in a year Performs task with prompting and/or support	Knows the number and the names of the months in a year Performs task independently
Knows the number of days in a week and year	Knows the number of days in a week and year Unable to perform task	Knows the number of days in a week and year Performs task with prompting and/or support	Knows the number of days in a week and year Performs task independently
Knows the number of weeks in a month and year	Knows the number of weeks in a month and year Unable to perform task	Knows the number of weeks in a month and year Performs task with prompting and/or support	Knows the number of weeks in a month and year Performs task independently
Reads time in five minute intervals (analog and digital clock)	Reads time in five minute intervals (analog and digital clock) Unable to perform task	Reads time in five minute intervals (analog and digital clock) Performs task with prompting and/or support	Reads time in five minute intervals (analog and digital clock) Performs task independently
Reads time in one minute intervals (analog and digital clock)	Reads time in one minute intervals (analog and digital clock) Unable to perform task	Reads time in one minute intervals (analog and digital clock) Performs task with prompting and/or support	Reads time in one minute intervals (analog and digital clock) Performs task independently
Reads time to the hour (analog and digital clock)	Reads time to the hour (analog and digital clock) Unable to perform task	Reads time to the hour (analog and digital clock) Performs task with prompting and/or support	Reads time to the hour (analog and digital clock) Performs task independently
Reads time to the quarter hour (analog and digital clock)	Reads time to the quarter hour (analog and digital clock) Unable to perform task	Reads time to the quarter hour (analog and digital clock) Performs task with prompting and/or support	Reads time to the quarter hour (analog and digital clock) Performs task independently
Understands the concept of "Today"	Understands the concept of "Today" Unable to perform task	Understands the concept of "Today" Performs task with prompting and/or support	Understands the concept of "Today" Performs task independently
Understands the concept of "Tomorrow"	Understands the concept of "Tomorrow" Unable to perform task	Understands the concept of "Tomorrow" Performs task with prompting and/or support	Understands the concept of "Tomorrow" Performs task independently
Understands the concept of "Yesterday"	Understands the concept of "Yesterday" Unable to perform task	Understands the concept of "Yesterday" Performs task with prompting and/or support	Understands the concept of "Yesterday" Performs task independently

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* 12. Comments

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* 13. Money Management

	Unable to perform task	Performs task with prompting and/or support	Performs task independently
Counts and makes change	Counts and makes change Unable to perform task	Counts and makes change Performs task with prompting and/or support	Counts and makes change Performs task independently
Identifies the value of coins and dollar bills	Identifies the value of coins and dollar bills Unable to perform task	Identifies the value of coins and dollar bills Performs task with prompting and/or support	Identifies the value of coins and dollar bills Performs task independently
Understands how one obtains money (earn)	Understands how one obtains money (earn) Unable to perform task	Understands how one obtains money (earn) Performs task with prompting and/or support	Understands how one obtains money (earn) Performs task independently
Understands the difference between saving and spending	Understands the difference between saving and spending Unable to perform task	Understands the difference between saving and spending Performs task with prompting and/or support	Understands the difference between saving and spending Performs task independently
Uses a calculator to add, subtract, multiply, and divide	Uses a calculator to add, subtract, multiply, and divide Unable to perform task	Uses a calculator to add, subtract, multiply, and divide Performs task with prompting and/or support	Uses a calculator to add, subtract, multiply, and divide Performs task independently
Uses a vending machine	Uses a vending machine Unable to perform task	Uses a vending machine Performs task with prompting and/or support	Uses a vending machine Performs task independently

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* 14. Comments

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* 15. Safety

	Unable to perform task	Performs task with prompting and/or support	Performs task independently
Answers the phone safely without giving out personal information	Answers the phone safely without giving out personal information Unable to perform task	Answers the phone safely without giving out personal information Performs task with prompting and/or support	Answers the phone safely without giving out personal information Performs task independently
Avoids touching chemicals (paint, cleaning products) without an adult present	Avoids touching chemicals (paint, cleaning products) without an adult present Unable to perform task	Avoids touching chemicals (paint, cleaning products) without an adult present Performs task with prompting and/or support	Avoids touching chemicals (paint, cleaning products) without an adult present Performs task independently
Does not take medication that isn't prescribed	Does not take medication that isn't prescribed Unable to perform task	Does not take medication that isn't prescribed Performs task with prompting and/or support	Does not take medication that isn't prescribed Performs task independently
Knows fire safety and escape routes at home	Knows fire safety and escape routes at home Unable to perform task	Knows fire safety and escape routes at home Performs task with prompting and/or support	Knows fire safety and escape routes at home Performs task independently
Knows how to make emergency calls	Knows how to make emergency calls Unable to perform task	Knows how to make emergency calls Performs task with prompting and/or support	Knows how to make emergency calls Performs task independently
Knows own address and phone number (911)	Knows own address and phone number (911) Unable to perform task	Knows own address and phone number (911) Performs task with prompting and/or support	Knows own address and phone number (911) Performs task independently
Takes medication only with an adult present	Takes medication only with an adult present Unable to perform task	Takes medication only with an adult present Performs task with prompting and/or support	Takes medication only with an adult present Performs task independently
Understands stranger safety rules (do not go with anyone not authorized by parent)	Understands stranger safety rules (do not go with anyone not authorized by parent) Unable to perform task	Understands stranger safety rules (do not go with anyone not authorized by parent) Performs task with prompting and/or support	Understands stranger safety rules (do not go with anyone not authorized by parent) Performs task independently
Wears a helmet when riding a bike, skateboard, scooter, or rollerblades	Wears a helmet when riding a bike, skateboard, scooter, or rollerblades Unable to perform task	Wears a helmet when riding a bike, skateboard, scooter, or rollerblades Performs task with prompting and/or support	Wears a helmet when riding a bike, skateboard, scooter, or rollerblades Performs task independently
Wears a seatbelt at all times	Wears a seatbelt at all times Unable to perform task	Wears a seatbelt at all times Performs task with prompting and/or support	Wears a seatbelt at all times Performs task independently

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* 1. Student Information

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* 2. Gender

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* 3. Social Skills

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* 4. Comments

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* 5. Personal Grooming

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* 6. Comments

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* 7. Household Tasks

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* 8. Comments

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* 9. Food Management

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* 10. Comments

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* 11. Time Management

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* 12. Comments

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* 13. Money Management

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* 14. Comments

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* 15. Safety

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* 16. Comments