Olympic Educational Service District 114

105 National Avenue North, Bremerton, Washington 98312

(360) 478-6887  1-800-201-1300  FAX (360) 405-5808

PARENT BASELINE QUESTIONNAIRE

Child’s Name: Click or tap here to enter text. Date: Click or tap to enter a date.

Please answer the following questions about your child:

(1c) I can take care of my own needs.

I use the toilet on my own: Choose an item.

I wash my hands and use a towel to dry them: Choose an item.

I put my toys away: Choose an item.

I engage in 1 activity of my own choosing: Choose an item.

(2a) I can separate from my parent without distress and engage with trusted adults: Choose an item.

(2b) I can tell how someone else is feeling and what caused them to feel that way: Choose an item.
Example: “My brother is sad because his toy broke.”

(3a) I share my toys with others: Choose an item.

(3b) I offer solutions to problems: Choose an item.
Example: “Sister is crying because she wants to ride my bike. She can have a turn and then I can have a turn.”

(9a) I can describe and tell the use of many familiar items: Choose an item.
Example: “When it rains, we use the umbrella to stay dry”, or “I water the plants with the hose”, or “I need shoes before I go outside.”

(9b) When I speak, other people can understand me: Choose an item.

(9c) I speak in long, complex sentences and follow most grammatical rules: Choose an item.
*Please give an example of a typical sentence your child might say: Click or tap here to enter text.

(9d) I tell stories about things I have done before: Choose an item.
Example: “I went to lunch with Grandma and I had chicken and broccoli.”

(12a) I can recognize familiar people, places, objects, and events: Choose an item.

(12a) I can tell about experiences in order: Choose an item.
Example: “When we make a sandwich, first we spread the peanut butter on the bread. Next, we spread the jelly and then we put them together to eat”, or “At bedtime, I take a bath, brush my teeth, read books, and turn out the light.”

(12b) I can apply past experiences to new situations: Choose an item.
Example: Uses traffic directing at the park on a bike path after having seen a police officer using traffic signals.

(14a) When I draw a picture, I can name what I draw: Choose an item.

(14b) I enjoy pretend play. I come up with the play scenario and sometimes I use props or make-believe objects to act out my play scenario: Choose an item.

(18a) I ask questions when books are read and like to look at the pictures: Choose an item.

(18b) I pretend to read my favorite books. I use some of the words from the story and I use pictures to order events: Choose an item.

(18c) I like to re-tell my favorite books using the pictures: Choose an item.

How many minutes a day do you read to your child? Click or tap here to enter text.

Children are always learning. Children learn from their caregivers, peers, and surroundings. How much time each day do you engage in conversations, laugh, play, and interact with your child?
Click or tap here to enter text.