Student’s name Student’s birthdate School Student’s SSID Teacher Assessment given in: q English q Spanish q Other
Date Social Emotional/Self
1
2
3
4
5
6
Never (0 pts)Emerging (1 pt)Usually (3 pts)Always (5 pts)
5 pts each
Cooperative/5
5 pts each
Respectful/5
5 pts each
Self Regulates/5
5 pts each
Independent/5
5 pts each
Attentive listener/5
5 pts each
Transitions away from parents smoothly/5
subscore
/30 total
Mathematics
Rote Counting
Counts to 5-9
Counts to 10-14
Counts to 15-19
Counts to 20 or more
Number Naming
Names 0
Names 1
Names 2
Names 3
Names 4
Names 5
1-1 Correspondence
Counts with 1-1 Correspondence to 5
Names
Names
Names
Names
Shape Recognition
10 1 pt each
Circle
Square
Triangle
Rectangle
Patterning
Extends pattern one step
Extends pattern two steps
11 2 pts each
7
8
9
2 pts each
1 pt each
1 pt each
subscore
Language and Literacy
12 2 pts each
Lowercase Letter Recognition
Names 3-5
Names 6-8
13 2 pts each
Uppercase Letter Recognition
Names 3-5
Names 6-8
14 2 pts each
15 5 pts
16 2 pts each
17 1 pt each
Names 9-11
/4 /27 total
/8
Names 9-11
Names 12 or more
Knows
Points
to
Predicts what
Finds front
Concepts of Print
print carries
first word
story is about
of book
meaning
Name Recognition
Child recognizes name
Name Writing
Writes a few letters
Writes most letters
Writes full first name
Speech is Understandable
50-75% is intelligible
At least 75% intelligible
/8
subscore
Self-Portrait
Draws self
with 3 parts
Additional Information
Gender: q Male q Female
IEP: q Yes q No
English Learner: q Yes q No
Attended Preschool: q Yes q No
Attended Playgroup: q Yes q No
Pencil Grip: q Fisted q Tripod
Handedness: q Right q Left q Undecided
Ethnicity _______________________________
Concerns/Comments
Draws self
with 6 parts
Draws self
with 9 parts
/4
Names 12 or more
Self-Portrait
18 2 pts each
/8
/6
/5
© 2012 Humboldt County Office of Education (HCOE). Permission to copy with attribution to HCOE is hereby granted. (4/1/13/SchSup/CindiK/HCKinScreenTool_2)
Humboldt County Kindergarten Screening Tool
/8
/5
/6
/2
/37 total
/6
subscore
/6 total
Total Score
/100
/26 UC letters
/26 LC letters