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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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