CHECKLIST ON DIFFICULTY IN APPLYING KNOWLEDGE

(LANGUAGE, MATHEMATICS, SOCIAL SCIENCES)

Name of Student: ___________________________________ Age:______
Grade and Section: _____________________ Subject:___________
Time, Date &Duration of Observation:_____________________________

Direction: The following manifestations may be displayed by your learner. Please check the
appropriate column for each.
INDICATORS Yes No
1. Difficulty learning connections between letters and sounds
2. Frequently adds and/or forgets letters in a word
3. Difficulty in remembering simple sequences
4. Difficulty keeping in place when reading
5. Poor sequencing of numbers
6. Poor spelling
7. Avoids reading aloud
8. Difficulty organizing ideas to speak or write
9. Slow to memorize tasks and math facts
10. Trouble following oral instructions
11. Appearing restless or easily distracted
12. Poor in spelling
13. Difficulty organizing to speak or write
14. Slow implementation of verbal directions that involve sequencing and planning
15. Inattentiveness about details when writing
16. Inconsistencies: mixing print/cursive and upper/lower case letters, irregular shapes, sizes
or slant of letters
17. Struggles to recognize patterns, such as smallest to largest or tallest to shortest
18. May still use fingers to count instead of using more advanced strategies like mental Math
19. Struggles to understand words related to Math, such as greater than and less than
20. Has trouble on visual-spatial representations of numbers, such as number line
21. May have low self-esteem
22. Impulsive in blurting out incorrect answers
23. Is clowning around and do inappropriate things and actions
24. Is bored and careless
25. Is embarrassed by attention
26. Has trouble writing numerals clearly or putting them in the correct column
27. Has trouble in understanding or using unspoken language
28. Maybe frustrated with school works
29. Easily to give up/unfinished task
30. Has difficulty in organizing data/facts

Observer with Signature: ___________________________

Comments/feedback:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

NOTE:
If the student scored or achieved 25% of the given indicators, it indicates that he/she manifests the given
difficulty.

This checklist was created by Melany C. Fernandez (IE Program Coordinator), and validated by Maria Antonette
Salvador (School Guidance Counselor III) and Cherry Ann Villar (Psychometrician) of San Juan National High School,
Division of San Juan City.
 CHECKLIST ON DIFFICULTY IN REMEMBERING, CONCENTRATING, PAYING
ATTENTION AND UNDERSTANDING

Name of Student: ___________________________________ Age:______

Grade and Section: _____________________ Subject:___________
Time, Date &Duration of Observation:_____________________________

Direction: The following manifestations may be displayed by your learner. Please check the
appropriate column for each.

INDICATORS Yes No
1. Poor Memory
2. Talks and laughs in unnecessarily loud voice
3. Tendency to over react to events and people around him
4. Does not care about the feelings of others
5. Tendency to be alone most of the time
6. Easily cries
7. Tendency to get angry at a slight provocation
8. Does not laugh easily when confronted with funny situations
9. Has short attention span
10. Has difficulty in comprehending situations in communication
11. Is easily distracted around him/her
12. Has difficulty in finishing work that has been started
13. Perseverates of repeats unnecessary action
14. Has difficulty in relating isolated facts into meaningful ideas
15. Refuses to talk/speak
16. Has the tendency to speak in words or phrases instead
17. Tendency to talk in sentences with grammatical errors
18. Has immature or improper vocabulary
19. Has tendency to repeat the instructions
20. Has difficulty in understanding directions/instructions to the given tasks.

Observer with Signature: ___________________________

Comments/feedback:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

NOTE:
If the student scored or achieved 25% of the given indicators, it indicates that he/she manifests the given
difficulty.

This checklist was created by Melany C. Fernandez (IE Program Coordinator), and validated by Maria Antonette
Salvador (School Guidance Counselor III) and Cherry Ann Villar (Psychometrician) of San Juan National High School,
Division of San Juan City.
 CHECKLIST ON DIFFICULTY IN APPLYING/PERFORMING ADAPTIVE SKILLS

Name of Student: ___________________________________ Age:______

Grade and Section: _____________________ Subject:___________
Time, Date &Duration of Observation:_____________________________

The following manifestations may be displayed by your learner. Please check the appropriate column
for each.
INDICATORS YES NO
 Inattention
1. Easily distracted by huge stimuli like sounds, lights, movement in the environment
2. Does not seem to listen when spoken to, thoughts are elsewhere
3. Difficulty following and remembering directions; forgetful in daily activities; fails to pay attention to details
4. Difficulty following instructions and fails to finish school works, chores or duties in workplace; makes many
careless mistakes
5. Poor study skills; weak executive functions
6. Appears confused
7. Easily overwhelmed
8. No awareness of time
9. Loses things necessary for tasks or activities
10. Difficulty initiating or getting started on tasks; reluctant to engage school tasks
11. Difficulty sustaining attention in assigned tasks and play activities; gets bored easily; fails to organized them
12. Difficulty sustaining level of alertness to tasks that are dull; sluggish or may fall asleep easily in class
13. Difficulty completing work; performance is inconsistent
 Hyperactivity
1. Highly energetic; Almost nonstop motion; “Always on the go”
2. Leaves seat and roams around the classroom; Can’t sit still
3. Restlessness; Squirms in seat
4. High degree of unnecessary movements like pacing, tapping feet, drumming fingers
5. Seems to need something in hands;
6. Finds/reaches objects to play with and/or puts in mouth High pain tolerance
7. Lack of regard for quality of outputs/tasks done
8. Delay in social maturation
9. Possible academic underachievement
10. Possible language communication lags
11. Seeking everyone’s attention
 Impulsivity
1. Talks excessively; blurts out answers before questions; making tactless comments; makes inappropriate or
odd noises
2. Difficulty with raising hand and wanting to be called; wants things “NOW”
3. Interrupts or intrudes on others; butts in
4. Conversation or games; disrupts or bother others
5. Hits when upset or grabs things away from others
6. Difficulty in waiting turn in activities and games; begins tasks without waiting for directions; hurries through
tasks; does not take time to correct and edit work
7. Cannot keep hands and feet to self
8. Difficulty standing in lines; gets easily bored; impatient
9. Knows the rules but repeatedly makes errors
10. Fearless, engage in physically dangerous activities like jumping from heights, riding bikes into streets
without looking
11. Fearless, engage in physically dangerous activities like jumping from heights, riding bikes into streets
without looking
 Others
1. High pain tolerance
2. Lack of regard for quality of outputs/tasks
3. done
4. Delay in social maturation
5. Possible academic underachievement
6. Possible language-communication lags
7. Possible learning disabilities

Observer with Signature: ___________________________

This checklist was created by Melany C. Fernandez (IE Program Coordinator), and validated by Maria Antonette
Salvador (School Guidance Counselor III) and Cherry Ann Villar (Psychometrician) of San Juan National High School,
Division of San Juan City.
 CHECKLIST ON DIFFICULTY IN MOBILITY

Name of Student: ___________________________________ Age:______

Grade and Section: _____________________ Subject:___________
Time, Date &Duration of Observation:_____________________________

Direction: The following manifestations may be displayed by your learner. Please check the
appropriate column for each.

INDICATORS Yes No
1. Paralysis
2. Altered muscle tone
3. Unsteady gait
4. Loss of or inability to use one or more limbs
5. Difficulty with walking, jumping gross-motor skills (running)
6. Difficulty with fine-motor skills buttoning, clothing, writing
7. Staying in one body position
8. Changing in body position
9. Standing/bending/lying
10. Transferring oneself (moving from surface to another)
11. Lifting/carrying/moving objects/handling objects
12. Have trouble with walking, running, climbing
13. Have work that appears sloppy

Observer with Signature: ___________________________

Comments/feedback:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

CHECKLIST ON DIFFICULTY IN COMMUNICATION

INDICATORS Yes No
1. Distortions
2. Substitutions
3. Additions
4. Deficient oral motor skills (e.g. “thoup” for “soup”)
5. Learner substitutes a sound for another sound. (e.g. “wabbit” for “rabbit” where “w” is
substituted for “r”.)
6. Learner drops (omits) a sound from a word. (e.g. “at” for “hat” or “bu” for “bug”.)
7. Adds a sound that shouldn’t be there (e.g. “doga” for “dog”)
8. Articulation Difficulty/Disorder
9. Voice Difficulty/Disorder
10. Fluency Difficulty/Disorder

Observer with Signature: ___________________________

Comments/feedback:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

This checklist was created by Melany C. Fernandez (IE Program Coordinator), and validated by Maria Antonette
Salvador (School Guidance Counselor III) and Cherry Ann Villar (Psychometrician) of San Juan National High School,
Division of San Juan City.
 CHECKLIST ON DIFFICULTY IN DISPLAYING INTERPERSONAL BEHAVIOR
Name of Student: ___________________________________ Age:______
Grade and Section: _____________________ Subject:___________
Time, Date &Duration of Observation:_____________________________

Direction: The following manifestations may be displayed by your learner. Please check the appropriate column
for each.
INDICATORS Yes No
1. Bullies and threatens classmates and others
2. Initiates physical fights
3. Has little empathy for others and a lack of appropriate feelings of guilt.
4. Lies to peers or teachers
5. Steals from peers or the school
6. Shows fearfulness and apprehension
7. Has difficulty in mingling/interacting with others
8. Has low self-esteem masked by showing boldness intended to impress or intimidate
9. Afraid of consequences of activities
10. Constantly seeks affirmation from others.
11. Deliberately annoys others
12. Worries about things that might happen or have happened.
13. Criticizes self and others.
14. Avoids things or places or refuses to do things or go places.
15.Expresses feelings of worthlessness, hopelessness
16. Blames self and others for one’s mistakes or misbehaviour
17. Has lack of interest to classroom/school activities
18. Thinks or talks repeatedly of suicide
19. Afraid of failure, rejection and embarrassment
20. Avoids work activities that involves contact with others
21. Good at flattering and manipulating other people’s emotions.
22. Has the tendency to use and abuse prohibited drugs and alcohol
23. Defies and refuses to comply with rules and teacher’s requests
24. Fails to pay attention
25. Difficulty in sustaining attention
26. Does not follow instruction and fails to complete task
27. Easily distracted
28. Talks excessively
29. Blurts out answer
30. Interrupts or intrude others
31. Have difficulty in understanding another person’s perspective
32. Have problems negotiating or advocating for themselves
33. Have feeling of incompetence
34. Is unable to predict consequences for behavior
35. Appear to be stubborn
36. Display violent behavior
37. Get unusually frustrated when trying to do simple task
38. Avoid or rarely make eye contact with others
39. Do not pay attention or focused on an activity

Observer with Signature: ___________________________

Comments/feedback:______________________________________________________________________
_______________________________________________________________________________________
NOTE:
If the student scored or achieved 25% of the given indicators, it indicates that he/she manifests the given
difficulty.

This checklist was created by Melany C. Fernandez (IE Program Coordinator), and validated by Maria Antonette
Salvador (School Guidance Counselor III) and Cherry Ann Villar (Psychometrician) of San Juan National High School,
Division of San Juan City.