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The purpose of the Basic Skills Checklist is to provide sending and receiving school teams with the basic information that will be
needed to set instructional goals for a potential student. Read each item in the Basic Skills Checklist, and type answers directly
in the boxes. Email completed form to specialist and receiving teacher. Use a second page for comments if needed.

School: Date:
Student: ID No. DOB: Age:

IEP Date: Eval. Date: Disability: Related Services: Grade:

Name and Date of Test(s):

Other Test Results:

Strengths: Weaknesses: Needs:

Does student have a FBA/BIP? If so, list the date and behavior(s):
Does student need a DA? If so, list the reason(s):
List Related Service(s):
Comment(s) from Related Service(s):

Evidence of Basic Skills

Academic Social Yes No
Recites ___ letters of the alphabet Follows simple directions
Recognizes ___ upper or lower case letters Expresses feelings and needs
Traces/prints letters Plays with other students
Rote counts to _ Shares with other students
Recognizes numbers Waits for his turn
Counts a group of objects Talks in phrases or sentences
Recognizes shapes Says “please” and “thank you”
Recognizes colors Goes to restroom by him
Sorts items by color, shape, or size:
Names ___ coins:
Recognizes own name in print:
List Other Skills:
Instructional Levels:

Fine Motor Yes No Gross Motor Yes No

Holds pencil or crayon Runs and jumps
Holds scissors correctly Walks up and down stairs
Puts a 5- to 10-piece puzzle Navigates hallways

Self-Help Yes No Personal Information Yes No
Dons and doffs clothing Knows full name
Feeds self Knows his age
*Independent toileting skills Knows address and phone number
Tie shoelaces Knows mother’s name
Takes care of personal items Knows father’s name
*If student does not have independent toileting skills, list strategies that are currently being utilized (at school and/or
home) to assist student (with toileting skills):


Prepared by : _____ __________________________

Teacher : _____ __________________________

Date : _____ __________________________