AUTISM SPECTRUM DISORDER (ASD) ASSESSMENT TEACHER QUESTIONNAIRE (6-18 YEARS)

Student's Details

Student’s Surname *

Student's Given Name *

Student's Age

Student's Grade/Year Level *

Student's Gender

MaleFemaleOther

If "other", please list preferred pronoun

Name of Person(s) Completing This Questionnaire *

Teacher/School E-mail Contact

Name of School

Does the student receive special assistance at school e.g. speech therapy, special education, NEP?

YesNoNot presently, but has in the pastNot presently, but will be in the future

If yes or will be, please list supports

Directions

ASD assessments are carried out based on the specific behavioural traits that an individual presents with in all facets of their lives based on the Diagnostic and Statistical Manual of Mental Disorders 5th Edition (DSM-V). Most ASD assessments are conducted in a clinical setting with no access to the way in which the student interacts with the outside world. Therefore, questionnaires are provided to those who work with the student to allow the clinician access to the way in which the student interacts beyond the clinical setting. Where possible, please provide as much information and examples to ensure an accurate view of the student's capabilities. Appropriate diagnosis of ASD requires the observation of particular behaviours across various domains in the child's life. School is a critical environment and so your reports of behaviours and examples play a critical role in our assessment and diagnosis. We thank you for your responses.

Academic Achievement Level

Rate the student’s confidence in his/her own academic abilities

Below AverageAverageAbove Average

Overall, does the student struggle with their learning?

YesNoUnsure

If the student is struggling with their learning, do you have a sense of why this may be? Please explain

Has the student had any other difficulties or areas of concern noted with regards to their learning?

YesNoUnsure

If yes, please describe

Temperament

Does the student struggle to transition between activities (e.g. have to complete all tasks before moving on)? If yes, please provide examples

Does the student struggle to wait for their turn when engaged in games? If yes, please provide examples

Is the student easily distracted? If yes, please provide examples

Does the student avoid listening/talking activities? If yes, please provide examples

Does the child demonstrate any unusual interests (e.g. fixation on certain items/topics/activities)? If yes, please describe

Does the student need to follow strict/pedantic routines? If yes, please provide examples

Please comment on the student's overall temperament

Social Skills

Does the student engage with their peers successfully? please comment on the students ability to make and maintain friendships

Does the child show, bring, or point out objects of interest to the teacher or their peers? (e.g. do they share events/items they are proud of or engaged in? Please provide examples

Does the student demonstrate empathy and comment on their emotions and those of others around them? Please describe

Is the student able to engage in reciprocal conversation (the student's ability to initiate, maintain/sustain conversation by asking questions and providing appropriate responses)? Please provide examples

Is the student able to maintain close friendships, or are their friendships superficial ? Please comment

Does the student engage with her teachers appropriately (do they adjust their behaviour between peers and adults/are they aware of social hierarchies)? Please comment

Please comment on the student's overall social engagement

Emotional Skills

Does the student demonstrate empathy (how do they react when others are upset/hurt)? Do they ever show concern for others? Please comment

Does the student manage their emotions when they are upset/hurt? Do they seek comfort? Can they self regulate? Please comment

Does the student have temper tantrums/meltdowns? Please comment

If the student does tend to have big emotions such as tantrums and tears, what tends to cause these outbursts? Please comment

Does the student tend to be overly anxious (afraid to engage in new activities and tasks)? Please provide examples

Please comment on the student's overall emotional regulation

Non-Verbal Behaviour

Does the student demonstrate appropriate eye contact? Do they look at you when conversing/communicating? Please comment

Does the student utilise gesture and body language to convey their needs, express feelings (do they use descriptive gestures such as using hands to point, cross their arms, wave, nod/shake their heads etc.)? Please provide examples

Does the child vary their facial expressions (do they demonstrate a series of emotions across their facial expressions)? Please describe

Is the student able to read and understand the non-verbal communication of others ( are they able to read body language and facial expressions of those around them)? Please comment

Sensory Needs

Does the student demonstrate increased sensitivity to any sounds/background noise? Please comment

Does the student seek/avoid touching certain textures (e.g. glue, sand, paint etc.)? Please provide examples

Does the student demonstrate unusual interest in certain smells (e.g. like sniffing food, objects or people)? Please provide examples

Does the student demonstrate unusual oral behaviours? (mouthing/chewing clothes, objects or people)? Please comment

Does the student demonstrate an apparent indifference to varying temperatures (e.g. not removing jumpers when very hot)? Please provide examples

Does the student demonstrate an unusual pain threshold (not reactive when hurt or over-reactive to small bumps and scratches) ? Please comment

Please comment on the student's overall sensory needs

General

What do you see to be the student's strengths?

What are you most concerned about with regards to the student's current performance?

Please note any additional information you believe would be pertinent for the assessor to note

Disclosure of Information

Please be aware that the contents of this questionnaire can and will be shared with the parent(s)/guardian(s) who have requested the ASD assessment be conducted.

Consent

Teacher Name (please print name) *

Signature *

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Date *