| Name: | |
| Date of Birth: | |
| Date of Screening: | |
| Screened by: |
| Skill | Yes | No | Notes |
|---|---|---|---|
| Can pick up small objects using thumb and index finger | |||
| Uses both hands together during activities | |||
| Can copy simple lines and shapes | |||
| Can button/unbutton clothing | |||
| Can use scissors to cut along a line | |||
| Can hold and use crayons/pencils appropriately | |||
| Can stack small blocks (at least 5) | |||
| Can thread large beads onto a string |