BASIC SKILLS CHECKLIST

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
adequately
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:
Comments:

Fine Motor Yes No Gross Motor Yes No

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

.
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):

Comments:

Prepared by : _____ __________________________

Teacher : _____ __________________________

Date : _____ __________________________