Fillable MFA for PreSchool (City of Oakland)

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MFA for PreSchool (City of Oakland)

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U.S.A. forms for City of Oakland

BROWSE CITY OF OAKLAND (CA) FORMS

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MFA for PreSchool
BALANCE, GROSS & FINE MOTOR CONTROL:
1) Consistently walks on tiptoes
Frequently Always
2) Avoids movement activities (swings, climbing, playground activities)
Never Occasionally Frequently Always
3) Bumps into people/objects; gets too close to others; is unaware of
personal space
Never Occasionally Frequently Always
4) Exhibits poor endurance, is weak and tires easily, avoids physical activity
Never Occasionally Frequently Always
Always
5) Seems clumsy, awkward, or accident prone
Never Occasionally Frequently
6) Demonstrates poor eye-hand coordination
Never Occasionally Frequently Always
7) Has difficulty with combining or remembering next movement in a sequence
Never Occasionally Frequently Always
Never Occasionally
Scoring Key:
Never - 0
Occasionally - 1
Frequently - 2
Always - 3
8) Avoids playing with toys that require increased dexterity (fine
motor manipulation)
Never Occasionally Frequently Always
9) Has difficulty catching things
Never Occasionally
Frequently Always
10) Exhibits poor balance and falls easily, avoids balance-related
activities (scooter, teeter totter)
Never Occasionally Frequently Always
11) Demonstrates a poor sense of rhythm, timing
Always
12) Has difficulty learning fine motor tasks, such as using crayons, building
blocks or scissors
Never Occasionally Frequently Always
13) Has difficulty learning new motor activities (tricycle, swimming,
throwing, catching, climbing)
Never Occasionally Frequently Always
SENSORY:
14) Seems bothered by textures on body (i.e. sticky items, sand/dirt,
working with paint/glue, clothing fabrics/tags)
Never Occasionally Frequently Always
15) Resists dressing or seems uncomfortable in certain clothes; has
preferences for clothing textures
Never Occasionally Frequently
Never Occasionally Frequently Always
16) Avoids messy play; does not like face, hands, or feet to be dirty
Never Occasionally Frequently Always
17) Avoids many foods and/or foods with varying textures, such as fruit in
yogurt or nuts in a candy bar
Never Occasionally Frequently Always
18) Bothered by background noise (i.e., humming of lights, school
intercom, computers, fans)
Never Occasionally Frequently Always
19) Bothered by loud and/or unexpected sounds, such as intercom, door
closing loudly, flushing toilet, fire alarm
Never Occasionally Frequently Always
20) Doesn’t like being touched/over responds to unexpected touch bumps
Never Occasionally Frequently Always
21) Doesn’t notice pain or has a slow response to pain when hurt
Never Occasionally Frequently Always
22) Plays too roughly; hurts others inadvertently
Never Occasionally Frequently Always
23) Constantly on the move; seeks intense, crashing or rough play
Never Occasionally Frequently Always
24) Avoids sustained eye contact
Never Occasionally Frequently Always
25) Doesn’t seem to notice external sensory stimuli (touch, smells, noise )
Never Occasionally Frequently Always
Always
26) Has an activity level that seems unusually high
Never Occasionally Frequently
27) Has an activity level that seems unusually low
Never Occasionally Frequently
Always
SOCIAL / EMOTIONAL:
28) Appears irritable, short-tempered
Never Occasionally Frequently Always
29) Is easily overwhelmed, frustrated by daily life activities
Never Occasionally Frequently Always
30) Seems emotionally intense in most activities
Never Occasionally Frequently Always
31) Exhibits frequent mood fluctuations
Never Occasionally Frequently Always
32) Seems easily upset/hurt; takes a long time to recover
Never Occasionally Frequently Always
33) Does not transition smoothly from one activity to another (going from
reading group to recess, etc.)
Never Occasionally Frequently Always
34) Has difficulty making and keeping friends
Never Occasionally
Frequently
Always
35) Lacks confidence with new environments and new tasks
N Never Occasionally Frequently Always
Always
36) Is not affectionate, not touching or hugging
Never Occasionally Frequently
37) Avoids social situations; prefers to be alone
Never Occasionally Frequently
Always
38) Seems overly possessive with belongings; doesn’t share well
Never Occasionally Frequently Always
39) Responds with exaggerated emotion to external sensory stimuli
Never Occasionally Frequently Always
AUDITORY / LANGUAGE:
40) Has difficulty understanding what others are saying
Never Occasionally F Frequently Always
41) Says “What?” or “Huh?”, needs instructions repeated, prefers visual cues
Never Occasionally Frequently Always
42) Seems slow to react to speech/directions
Never Occasionally Frequently
Always
43) Dislikes shrill sounds, or popping sounds, such as fireworks, balloons
N Never Occasionally Frequently Always
44) Has difficulty determining from what direction a sound is coming
Never
Occasionally Frequently Always
45) Has difficulty discriminating spoken words or sounds (confuses similar
sounding words)
Never
Occasionally
Frequently Always
46) Is difficult to understand; doesn’t speak clearly; mumbles
Never Occasionally Frequently Always
47) Speaks with monotone voice
Frequently
Always
48) Has difficulty identifying and distinguishing between different
sounds or letters
Never
Occasionally
Frequently Always
49) Has difficulty rhyming words
Frequently
Always
50) Needs hands-on or visual instructions along with verbal
Never Occasionally Frequently
Always
Never Occasionally
Never Occasionally
51) Is unable to recall the number of letters, numbers, or words in a
series equivalent to his/her peers
Never Occasionally
Frequently
Always
52) Has difficulty responding to simple questions (who, what, where)
Never Occasionally Frequently Always
53) Has difficulty listening to short stories and is unable to maintain
attention too favorite ones
Never Occasionally Frequently Always
54) Is unable to remember two to three verbal instructions at a time to
complete sequence or task
Never Occasionally Frequently Always
55) Is unable to complete two unrelated commands (e.g., “Put your
book away; stand in line
Never Occasionally Frequently Always
ORGANIZATION / ATTENTION / COGNITIVE:
56) Has difficulty getting/finding backpack, jacket, materials to take home
Never Occasionally Frequently Always
57) Needs frequent redirection and/or refocusing toward task at hand
Never Occasionally Frequently Always
58) Gazes into space/appears to be in own world
Never Occasionally Frequently
Always
59) Has difficulty self-regulating actions and/or emotions
Never Occasionally Frequently
Always
60) Is easily distracted; not able to stay on task (shorter attention
span than peers)
Never
Occasionally
Frequently
Always
61) Has difficulty shifting attention from one activity or object to another
(more so than peers)
Never
Occasionally Frequently
Always
62) Has a tendency to ramble, can’t “get to the point”
Never Occasionally Frequently
Always
SLEEP:
63) Needs parent in the room to fall asleep
Never Occasionally Frequently Always
64) Lies awake for half an hour or more before falling asleep
Never Occasionally Frequently Always
65) Awakens more than once during the night
Always
Never Occasionally Frequently
66) Cannot get back to sleep easily
Never Occasionally Frequently
Always
67) Has fitful sleep cycles (tosses, turns, restless)
Never Occasionally Frequently
Always
68) Moves to someone else's bed during the night (parent, sibling, etc.)
Never Occasionally Frequently Always
69) Awakens during the night and is sweating, screaming and/or inconsolable
Never Occasionally Frequently Always
70) Seems hard to wake up in the morning
Never Occasionally
Frequently
Always
71) Wakes up grouchy, irritable, fussy and mood persists throughout the day
Never Occasionally Frequently Always
72) Feels sleepy and struggles to remain alert during day
Never
Occasionally
Frequently
Always
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MFA for PreSchool (City of Oakland)

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Completed 24 May 2021

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