Student Name: Date: Teacher/Therapist:
STUDENT ADVOCACY & INDEPENDENCE DEVELOPMENT
(SAID) Teacher Checklist
Use this checklist to monitor how well the student integrates important self-advocacy, independence activities, and
communication repair into their daily school life. Select the type of responses you have observed the student to use
or you think that the student is most likely to use.
SELF-ADVOCACY COMMUNICATION STYLE
PASSIVE (P): waits for others to notice
that he needs help; tends to nod and smile
even if he does not understand; meek or
timid; oversensitive to what others think;
may offer little during conversations; too
concerned with being liked by others;
accepts fault for misunderstanding and
may then feel bad about himself.
AGGRESSIVE (G): can become
sullen, angry or belligerent when does
not understand, blaming others for his
misunderstanding; can be insensitive to
the feelings of others including being
bossy during conversations with peers;
may be demanding or very outgoing in an
attempt to control the situation.
ASSERTIVE (S): recognizes that he has
the right to express needs; raises hand
or otherwise lets teacher know when he
has not understood; presents reasonable
and speciﬁc requests in a pleasant tone of
voice; assumes that a misunderstanding is a
shared or mutual responsibility; takes turns
and holds up own end of a conversation.
Student response when he…
(you may choose more than one response) Passive (P), Aggressive (G), Assertive (S)
NA* or Not
1. Does not hear all of a homework assignment P G S NA NO
2. Is working in a small group with others when it is noisy and difﬁcult for him to understand P G S NA NO
3. Has ‘gotten lost’ due to new vocabulary during verbal instruction or in written materials P G S NA NO
4. Is experiencing problems with his hearing technology not functioning P G S NA NO
5. Is conversing with a friend in a quiet environment (typical communication style) P G S NA NO
6. Is conversing with another student when it is noisy, such as during class transition times P G S NA NO
7. Is not understood and he is asked to repeat or clarify P G S NA NO
8. Does not understand single or multistep directions when class starts begins working independently P G S NA NO
9. Has difﬁculty understanding the presenter in the auditorium or over the intercom P G S NA NO
10. Does not understand the need to bring an important paper/money from home (due to mishearing) P G S NA NO
11. Does not hear information provided by another student during class discussion P G S NA NO
12. Is caught off guard after called upon to answer a question and it is clear that he is ‘lost’ P G S NA NO
Indicators of Independent Function
Rare Occasional Consistent
1. Using ampliﬁcation daily (personal device, FM) 0 1 2 3
2. Charging FM, monitoring hearing aid function 0 1 2 3
3. Promptly reporting issues with hearing technology 0 1 2 3
4. Selecting own seating (classroom, gym, auditorium) for best hearing 0 1 2 3
5. Independently closing door or asking that a noise source be stopped 0 1 2 3
6. Asking for clariﬁcation of assignments if needed 0 1 2 3
Never Rare Occasionally Sometimes Often
Asks for repetition Can you say that again more slowly please? 0 1 2 3 4
Asks for clariﬁcation
by using key words
in the request
Can you say the page again please?
Where are we in the math book?
Is it the odd problems on page 38?
0 1 2 3 4
Uses some sort of signal that he didn’t
understand that you two have agreed on
0 1 2 3 4
Looks confused and hopes you notice 0 1 2 3 4
Writes you a note 0 1 2 3 4
*NA= non-applicable, the situation does not happen in class for you to possibly observe.
Age Range: All Grades
© 2011 Karen Anderson and Kathy Arnoldi From Building Skills for Success in the Fast-Paced Classroom, page 397, Butte Publications.
Permission is granted to individuals who have purchased this form to reproduce or electronically share it only to serve their speciﬁc students. Sharing this content in any manner not related to a speciﬁc student’s education is prohibited.