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The following chart was part
of a comprehensive intervention plan the author
developed for a student with executive dysfunction.
The purpose of the following chart was to help the
student and team assess the student's perception of
his organizational skills and to start him thinking
about them on a daily basis. This form was part of
an integrated plan that provided specific
interventions for deficient skills.
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Date:
_________________________
Directions to Staff:
At the end of each day, [X] is to
request this form. If he doesn't request
it, he should be cued to ask for it. He
should independently complete the form,
review it with his paraprofessional or
resource room teacher and then turn it in
to him/her. Completed forms should be
saved in a file so that progress over the
course of the school year may be
determined.
[X]: Please
rate each of the items in the chart below
in terms of how well you think you did on
the task, where 1 is "not at all", 3 is
"average" and 5 is "very much or all." If
something wasn't possible for the day (for
example, if you had no papers in school to
file at all), you can just put a line
through that row for the day.
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ITEM
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1
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2
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3
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4
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5
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Recorded
all homework assignments
completely and accurately
(without cueing).
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Packed up
necessary materials for homework
at end of class period or day
("5" = needed no help or
reminders)
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Entered
long-term project deadlines or
test dates in planner.
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Worked on
breaking down long-term projects
or studying for tests into
intermediate deadlines and
entered intermediate deadlines in
planner.
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Showed
teacher(s) intermediate work
towards big project.
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Remembered
to go to school nurse to take
in-school medication today
(without cueing).
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Conformed
to school code of conduct by
acting appropriately.
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Once each
week, clean out files and
folders. On the last day of each
school week, circle Yes or No for
whether you did this. Otherwise,
leave this row blank.
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Notice what this type of
self-evaluation form can accomplish. It asks the
student to evaluate his own performance, enables
him to compare his assessment with those of the
adults in the classroom, and provides a daily
reminder of things that are important for him to
do. The form also became part of his monitoring for
achieving his IEP objectives. Such self-evaluation
forms are not intended as a sole intervention,
however, but as part of a comprehensive
plan.
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