Problem Checklist
Put Check if the situation is occurred.
He/ She was crying
He/ She injured from his/her classmates
He/ She have damage on his/her head, arms, thigh, etc.
He/ She has bite marks and wounds
He/ She is often easily disturbed y extraneous stimuli
He/ She is often loses things necessary for tasks or activities such as toys, school assignment etc.
He/ She I can’t talk or speak well because he/she feels shame and afraid
He/ She is often spiteful by his/her classmates
He/ She is often loses one’s temper
He/ She was hitting, kicking, or threatening to his/her classmates
He/ She pushed his/her classmates.
He/ She don’t get his/her personal things, and then he/she spanked his/her
He/ She has bullying his/ her classmates
He/ She was biting his/her classmates
He/ she always aggressive
He/ She is always say bad words to his/ her Classmates
He/ She are often angry and resentful to his/her classmates.
He/ She blame other classmates for one’s mistakes or misbehavior.
FOR TEACHERS
He/ She asked each of the children regarding the problem
He/ She were shouting to his/her children.
He/ She ignored the problem situation
He/ She shocked in the situation
He/ She is angry and take the children outside the room
He/ She used force to stop the quarreling or fighting between two children
He/ She used activities to catch up their attention
He/ She hurt his/her children.
He/ She talked to the children about the situation
He/ she didn’t know what happened and what he/she can do
He/ She were crying.
Please answer all items as well as you can, even if some do not seem to apply to the child.
A = Not True (as far as you know) B = somewhat or Sometimes True
C = Very True or Often True
A = Not True (as far as you know) B = somewhat or Sometimes True
C = Very True or Often True
A B C 1. Cries a lot
A B C 2. Cruel to animals
A B C 3. Defiant
A B C 4.. Demands must be met immediately
A B C 5. Destroys his/her own things
A B C 6. Destroys things belonging to his/her family
or other children
A B C 7. Diarrhea or loose bowels (when not sick)
A B C 8. Disobedient
A B C 9. Disturbed by any change in routine
A B C 10. Doesn’t want to sleep alone
A B C 20. Doesn’t answer when people talk to him/her
A B C 21. Doesn’t eat well (describe): ________________
______________________________________
A B C 22. Doesn’t get along with other children
A B C 23. Doesn’t know how to have fun; acts like a
little adult
A B C 24. Doesn’t seem to feel guilty after misbehaving
A B C 25. Doesn’t want to go out of home
A B C 26. Easily frustrated
A B C 27. Easily jealous
A B C 28. Eats or drinks things that are not food—don’t
include sweets (describe): _________________
______________________________________
A B C 29.Fears certain animals, situations, or places
(describe): _____________________________
______________________________________
A B C 30. Feelings are easily hurt
A B C 31 Gets hurt a lot, accident-prone
A B C 32. Gets in many fights
A B C 33. Gets into everything
LANGUAGE DEVELOPMENT
Be sure to answer all items.
I. Was your child born earlier than the usual 9 months after conception?
G No G Yes how many weeks early? ________weeks early.
II. How much did your child weigh at birth? ________ pounds ________ounces; or ________ grams.
III. How many ear infections did your child have before age 24 months?
G 0-2 G 3-5 G 6-8 G 9 or more
IV. Is any language beside English spoken in your home?
G No G Yes—please list the languages: ___________________ ___________________
___________________ ___________________
A B C 2. Cruel to animals
A B C 3. Defiant
A B C 4.. Demands must be met immediately
A B C 5. Destroys his/her own things
A B C 6. Destroys things belonging to his/her family
or other children
A B C 7. Diarrhea or loose bowels (when not sick)
A B C 8. Disobedient
A B C 9. Disturbed by any change in routine
A B C 10. Doesn’t want to sleep alone
A B C 20. Doesn’t answer when people talk to him/her
A B C 21. Doesn’t eat well (describe): ________________
______________________________________
A B C 22. Doesn’t get along with other children
A B C 23. Doesn’t know how to have fun; acts like a
little adult
A B C 24. Doesn’t seem to feel guilty after misbehaving
A B C 25. Doesn’t want to go out of home
A B C 26. Easily frustrated
A B C 27. Easily jealous
A B C 28. Eats or drinks things that are not food—don’t
include sweets (describe): _________________
______________________________________
A B C 29.Fears certain animals, situations, or places
(describe): _____________________________
______________________________________
A B C 30. Feelings are easily hurt
A B C 31 Gets hurt a lot, accident-prone
A B C 32. Gets in many fights
A B C 33. Gets into everything
LANGUAGE DEVELOPMENT
Be sure to answer all items.
I. Was your child born earlier than the usual 9 months after conception?
G No G Yes how many weeks early? ________weeks early.
II. How much did your child weigh at birth? ________ pounds ________ounces; or ________ grams.
III. How many ear infections did your child have before age 24 months?
G 0-2 G 3-5 G 6-8 G 9 or more
IV. Is any language beside English spoken in your home?
G No G Yes—please list the languages: ___________________ ___________________
___________________ ___________________
V. Has anyone in your family been slow in learning to talk?
G No G Yes—please list their relationships to your child; for example, brother, father:
________________________________________________________________________
G No G Yes—please list their relationships to your child; for example, brother, father:
________________________________________________________________________
VI. Are you worried about your child’s language development?
G No G Yes—why? ________________________________________________________
_____________________________________________________________
VII. Does your child spontaneously say words in any language? (not just imitates or understands words)?
G No G Yes—if yes, please complete item VIII and page 4.
VIII. Does your child combine 2 or more words into phrases? For example: “more cookie,” “car bye-bye.”
G No G Yes—please print 5 of your child=s longest and best phrases or sentences.
For each phrase that is not in English, print the name of the language.
1. _______________________________________________________________
2. _______________________________________________________________
3. _______________________________________________________________
4. _______________________________________________________________
5. _______________________________________________________________
Please circle each word that your child says SPONTANEOUSLY (not just imitates or understands).
FOODS
1. apple
2. banana
3. bread
4. butter
5. cake
6. candy
7. cereal
8. Cheese
9. coffee
10. cookie
TOYS
11. ball
12. balloon
13. blocks
14. book
15. crayons
16. doll
17. picture
18. present
19. slide
20. swing
BODY PARTS
21. arm
22. belly button
23. bottom
24. chin
25. ear
26. elbow
27. eye
28. face
29. finger
30. foot
Other words your child says,
including non-English words:
______________________________
______________________________
______________________________
______________________________
G No G Yes—why? ________________________________________________________
_____________________________________________________________
VII. Does your child spontaneously say words in any language? (not just imitates or understands words)?
G No G Yes—if yes, please complete item VIII and page 4.
VIII. Does your child combine 2 or more words into phrases? For example: “more cookie,” “car bye-bye.”
G No G Yes—please print 5 of your child=s longest and best phrases or sentences.
For each phrase that is not in English, print the name of the language.
1. _______________________________________________________________
2. _______________________________________________________________
3. _______________________________________________________________
4. _______________________________________________________________
5. _______________________________________________________________
Please circle each word that your child says SPONTANEOUSLY (not just imitates or understands).
FOODS
1. apple
2. banana
3. bread
4. butter
5. cake
6. candy
7. cereal
8. Cheese
9. coffee
10. cookie
TOYS
11. ball
12. balloon
13. blocks
14. book
15. crayons
16. doll
17. picture
18. present
19. slide
20. swing
BODY PARTS
21. arm
22. belly button
23. bottom
24. chin
25. ear
26. elbow
27. eye
28. face
29. finger
30. foot
Other words your child says,
including non-English words:
______________________________
______________________________
______________________________
______________________________
If Problems Arise
Sometimes child care programs
that are wonderful take a sudden
turn for the worse. That’s why it
is important to keep a watchful
eye and to continually monitor
your child care situation. If you
believe that your child care
arrangement is not safe, take
immediate action. If the situation
is serious, do not hesitate to find
alternative care right away.
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