Executive Functioning Reproducable Forms

Reproducible forms for
Executive Skills in Children and Adolescents, 2nd edition

by Peg Dawson and Richard Guare
Guilford Publications, Inc.
Form 2.1. Executive Skills Semistructured Form 5.7. Long-Term Project-Planning Sheet
Interview—Parent Version Form 5.8. Tools for Studying
Form 2.2. Executive Skills Semistructured A. Menu of Study Strategies
Interview—Teacher Version B. Study Plan
Form 2.3. Executive Skills Semistructured C. Posttest Evaluation
Interview—Student Version Form 5.9. Organizing Notebooks/Homework
Form 2.4. Executive Skills Questionnaire for A. Setting Up a Notebook/Homework
Parents/Teachers Management System
Form 2.5. Executive Skills Questionnaire for B. Maintaining a Notebook/Homework
Students Management System
Form 3.1. Executive Skills: Planning Form 5.10. Note-Taking Template: Cornell Method
Interventions
Form 5.11. Hard Times Board
Form 4.1. Forms for Developing Behavior
Form 5.12. Maintaining Self-Control
Plans/Incentive Systems
Form 5.13. Worry Board
A. Incentive Planning Sheet
Form 5.14. Managing Changes in Plans or
B. Contract
Schedules
Form 4.2. Executive Skills Self-Management
A. Surprise! Card
Checklist
B. Complaint Form
Form 4.3. Getting to Know You
Form 5.15. Learning Not to Cry over Little Things
Form 5.1. Morning Routine Checklist
A. Upset Log
Form 5.2. End-of-Day Routine Checklists
B. Contract
Form 5.3. Daily Homework Planner
Form 5.16. Solving Problems Worksheet
Form 5.4. Attention-Monitoring Checklist
Form 8.1. Progress Monitoring: Response to
Form 5.5. Desk Cleaning Checklist
Intervention
Form 5.6. Writing Template for a Five-Paragraph
Essay
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Form 2.1
Executive Skills Semistructured Interview—Parent Version

Many youngsters have problems in school or with homework not because they lack intelligence but
because they have weak executive skills. These refer to the skills required to plan/prioritize (P) and
carry out tasks, including time management (TM), working memory (WM), the ability to organize
tasks and materials (O), task initiation (TI) and follow-through, flexibility (F), response inhibition (RI),
emotional control (EC), sustained attention (SA), goal-directed persistence (GDP), and metacognition
(M). I’m going to ask you some questions about (fill in the child’s name) to
help us get a clearer understanding of his or her executive skills. Codes in parentheses refer to the
specific executive skill measured by each item.
HOMEWORK. Which of the following areas, if any, does your child have difficulty with?
Not a
Item Problem Notes
Understanding homework directions

(M)
Getting started on his or her own (TI)
Being able to keep working despite

distractions (SA)
Asking for help when it’s needed (M)
Sticking with it long enough to

complete it (SA, GDP)
Making careless mistakes; failing to

check work (M)
Finishing the work on time (TM)
Remembering to hand it in (WM)
Are there some subjects or kinds of assignments your child is more likely than others to complete
successfully?
More likely to be successful with . . . Less likely to be successful with . . .
(cont.)
From Dawson and Guare (2010). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchas-
ers of this book for personal use only (see copyright page for details).

Executive Skills Semistructured Interview—Parent Version (page 2 of 4)
ORGANIZATION OF MATERIALS. Which of the following areas, if any, does your child have difficulty
with?
Not a
Item Problem Notes
Keeping notebooks and papers organized (O)
Keeping desk tidy (O)
Keeping belongings neat and in appropriate locations

(e.g., gym clothes, coats, hats, mittens) (O)
Keeping track of books, papers, pencils, etc. (O)
Keeping backpack organized (O)
LONG-TERM PROJECTS. Which of the following areas, if any, does your child have difficulty with?
Not a
Item Problem Notes
Deciding on a topic (P)
Breaking the assignment into smaller parts (P)
Developing a timeline (P)
Following a timeline (TM)
Estimating how long it will take to finish (TM)
Following directions carefully (WM, M)
Proofreading or checking project to catch mistakes

to make sure the rules were followed (M)
Finishing the project by the deadline (GDP)
(cont.)

REMEMBERING. Which of the following areas, if any, does your child have difficulty with?
Not a
Item Problem Notes
Writing down assignments (WM
Bringing home appropriate materials (e.g., books,

workbooks, assignment book, worksheets,
notices, permission slips, gym clothes) (WM)
Bringing to school appropriate materials (see

examples above) (WM)
Remembering instructional sequences after

normal instruction (e.g., long division, proper
headings for papers) (WM)
Remembering to perform chores or other

household responsibilities (WM)
Losing things within the home, yard, or

neighborhood (WM)
PROBLEM SOLVING. Which of the following areas, if any, does your child have difficulty with?
Not a
Item Problem Notes
Recognizing that he or she has a problem (e.g.,

doesn’t understand the directions) (M)
Being able to think flexibly about the problem (e.g.,

not get stuck on one approach or solution) (F)
Trying to solve the problem first on his or her own

before going for help (M)
Accessing appropriate resources to help him or her

solve the problem (F)
Evaluating his or her own performance to know

whether the problem was solved successfully (M)
(cont.)

SELF-CONTROL. Some youngsters have difficulty managing their behavior. Which of the following
areas, if any, does your child have difficulty with?
Not a
Item Problem Notes
Becoming easily upset (EC)
Throwing temper tantrums (EC)
Acting impulsively, either verbally or

physically (e.g., provoking siblings) (RI)
Interrupting others (RI)
Difficulty waiting turn (RI)
PARENTAL EXECUTIVE SKILLS. Do you see yourself as having challenges in any of the areas we’ve
talked about? If so, in which areas?
Can you envision other problems with starting or following a plan? How or by whom could these
problems be managed?

Form 2.2
Executive Skills Semistructured Interview—Teacher Version

Many youngsters have problems in school or with homework not because they lack intelligence but
because they have weak executive skills. These refer to the skills required to plan/prioritize (P) and
carry out tasks, including time management (TM), working memory (WM), the ability to organize
tasks and materials (O), task initiation (TI) and follow-through, flexibility (F), response inhibition (RI),
emotional control (EC), sustained attention (SA), goal-directed persistence (GDP), and metacognition
(M). I’m going to ask you some questions about (fill in the child’s name) to
help us get a clearer understanding of his or her executive skills. Codes in parentheses refer to the
specific executive skill measured by each item.
INDEPENDENT SEATWORK. Which of the following areas, if any, does the student have difficulty
with?
Not a
Item Problem Notes
Understanding task directions (M)
Getting started on his or her own (TI)
Being able to keep working despite distractions (SA)
Asking for help when it’s needed (M)
Sticking with it long enough to complete it (SA, GDP)
Making careless mistakes; failing to check work (M)
Finishing the work on time (TM)
Remembering to hand it in (WM)
Are there some subjects or kinds of assignments that the student is more likely than others to
complete successfully?
More likely to be successful with . . . Less likely to be successful with . . .
(cont.)

Executive Skills Semistructured Interview—Teacher Version (page 2 of 4)
ORGANIZATION OF MATERIALS. Which of the following areas, if any, does the student have
difficulty with?
Not a
Item Problem Notes
Keeping notebooks and papers organized (O)
Keeping desk tidy (O)
Keeping belongings neat and in appropriate locations

(e.g., gym clothes, coats, hats, mittens) (O)
Keeping track of books, papers, pencils, etc. (O)
Keeping backpack organized (O)
LONG-TERM PROJECTS. Which of the following areas, if any, does the student have difficulty with?
Not a
Item Problem Notes
Deciding on a topic (P)
Breaking the assignment into smaller parts (P)
Following a timeline (TM)
Estimating how long it will take to finish (TM)
Following directions carefully (WM, M)
Proofreading or checking project to catch

mistakes to make sure the rules were followed
(M)
(cont.)

REMEMBERING. Which of the following areas, if any, does the student have difficulty with?
Not a
Item Problem Notes
Writing down assignments (WM)
Bringing home appropriate materials (e.g.,

books, workbooks, assignment book,
worksheets, notices, permission slips, gym
clothes) (WM)
Bringing to school appropriate materials (see

examples above) (WM)
Remembering to follow classroom procedures

(WM)
Losing things in the classroom or other places in

the school (e.g., lunchroom, gym, playground)
(WM)
Remembering instructional sequences after

normal instruction (e.g., long division, proper
headings for papers) (WM)
PROBLEM SOLVING. Which of the following areas, if any, does the student have difficulty with?
Not a
Item Problem Notes
Recognizing that he or she has a problem (e.g.,

doesn’t understand the directions) (M)
Being able to think flexibly about the problem (e.g.,

not get stuck on one approach or solution) (F)
Trying to solve the problem first on his or her own

before going for help (M)
Accessing appropriate resources to help him or her

solve the problem (F)
Evaluating his or her own performance to know

whether the problem was solved successfully (M)
(cont.)

SELF-CONTROL. Some youngsters have difficulty managing their behavior. Which of the following
areas, if any, does the student have difficulty with?
Not a
Item Problem Notes
Becoming easily upset (EC)
Throwing temper tantrums (EC)
Acting impulsively, either verbally or

physically (e.g., provoking siblings) (RI)
Interrupting others (RI)
Difficulty waiting turn (RI)
CURRENT EFFORTS TO ADDRESS THE PROBLEM. Please identify the current strategies or
interventions that are being used to address this student’s problem areas and indicate how successful
they are.
TEACHER EXECUTIVE SKILLS. Do you consider yourself as having challenges in any of the areas
we’ve talked about? If so, will this have an impact on your ability to put in place interventions to
address the student’s problem areas?

Form 2.3
Executive Skills Semistructured Interview—Student Version

I’m going to ask you some questions about situations related to your success as a student. All of these
are situations in which you have to use planning and organizational skills in order to be successful.
Some will be directly related to school, whereas other questions will touch on extracurricular activities,
any job situations you’ve been in, and how you spend your leisure time.
HOMEWORK. I’m going to ask you some questions about homework and the kinds of problems kids
sometimes have with homework. Please tell me if you think these are problems for you. I may ask you
to give me examples of how you see it as a problem.
Not a
Item Problem Notes
Getting started on homework. (TI)

Related questions: What makes it hard? When is
the best time to do homework? Are some subjects
harder to start than others?
Sticking with it long enough to get it done. (SA)

Related questions: Is this worse with some subjects
than others? What do you say to yourself that either
leads you to give up or stick with it? Does the
length of the assignment make a difference in your
ability to complete it?
Remembering assignments. (WM)

Related questions: Do you have trouble
remembering to write down assignments, bring
home necessary materials, or hand in assignments?
Do you lose things necessary to complete the task?
Becoming distracted while doing homework. (SA)

Related questions: What kinds of things distract
you? Have you found places to study that minimize
distractions? How do you handle the distractions
when they come up?
Having other things you’d rather do. (P, GDP)

Related questions: Are there things you have
trouble tearing yourself away from to do homework?
Do you resent having homework or too much
homework? Do you think there are other things in
your life that are more important than homework?
(cont.)

Executive Skills Semistructured Interview—Student Version (page 2 of 6)
LONG-TERM PROJECTS. Now let’s talk about long-term assignments. Which of the following, if any,
are hard for you?
Not a
Item Problem Notes
Choosing a topic (M)
Breaking the assignment into smaller parts

(P)
Sticking with a timeline (TM)
Estimating how long it will take to finish

(TM)
Following directions (e.g., Do you forget to do

part of the assignment and lose points as a
result?) (WM, M)
Proofreading or checking your work to make

sure you followed the rules and haven’t made
careless mistakes (M)
STUDYING FOR TESTS. Here are some problems students sometimes have when studying for tests.
Which ones, if any, are a problem for you?
Not a
Item Problem Notes
Making yourself sit down and study (TI)
Knowing what to study (M)
Knowing how to study (M)
Putting off studying/not studying at all (TM)
(cont.)

STUDYING FOR TESTS. (cont.)
Not a
Item Problem Notes
Taking breaks that are either too frequent or
too long (SA)
Giving up before you’ve studied enough
(GDP)
Memorizing the material (WM)
Understanding the material (M)
HOME CHORES/RESPONSIBILITIES. What kinds of chores, if any, do you have to do on a regular or

irregular basis?
Regular (When do
Chore you do it?) Occasional
1.
2.
3.
4.
5.
What aspects of completing chores, if any, do you have trouble with?
Not a
Item Problem Notes
Remembering to do them (WM)
Doing them when you’re supposed to (TI)
Running out of steam before you’re done (SA)
Doing a sloppy job and getting in trouble for it (M)
(cont.)

ORGANIZATIONAL SKILLS. Now I’m going to ask some questions about how organized you are. Tell
me if you have problems with any of the following.
Not a
Item Problem Notes
Keeping your bedroom neat (O)
Keeping your notebooks organized (O)
Keeping your backpack organized (O)
Keeping your desk clean (O)
Keeping your locker clean (O)
Leaving your belongings all over the house (O)
Leaving belongings other places (e.g., school,

friend’s houses, at work) (O)
Losing or misplacing things (O)
WORK/LEISURE TIME. Let’s talk about how you spend your time when you’re not in school. What
kinds of extracurricular activities, if any, are you involved in? Do you have a job? How do you spend
your leisure time?
Amount of time
Activity (approximate per day or week)
1.
2.
3.
4.
5.
6.
7.
(cont.)

Here are some problems that students sometimes have with how they spend their spare time. Which
ones, if any, are problems for you?
Not a
Item Problem Notes
Spending too many hours at a job (TM)
“Wasting” time (e.g., hanging out, playing computer/

video games, talking on the phone, time on
Facebook, watching too much TV) (TM)
Hanging out with kids who get in trouble (RI)
Not getting enough sleep (RI)
Spending money as soon as you get it (RI)
LONG-TERM GOALS. Do you know what you want to do after high school?
Possible goals
1.
2.
3.
4.
Have you formulated a plan for reaching your goal(s)? If so, what is it?
(cont.)

What are some of the potential obstacles that might prevent you from reaching your goal(s)?
Potential obstacle Ways to overcome the obstacle
1.
2.
3.
4.
5.
If you have not yet identified a goal or developed a plan for reaching the goal, when do you think you
will you do this?

Form 2.4
Executive Skills Questionnaire for Parents/Teachers

Big problem 1
Moderate problem 2
Mild problem 3
Slight problem 4
No problem 5
Item Score
1. Acts on impulse
2. Gets in trouble for talking too much in class
3. Says things without thinking
TOTAL SCORE:
4. Says, “I’ll do it later” and then forgets about it

5. Forgets homework assignments or forgets to bring home needed materials
6. Loses or misplaces belongings such as coats, mittens, sports equipment, etc.
TOTAL SCORE:
7. Gets annoyed when homework is too hard or confusing or takes too long to finish
8. Has a short fuse; easily frustrated
9. Easily upset when things don’t go as planned
TOTAL SCORE:
10. Difficulty paying attention; easily distracted

11. Runs out of steam before finishing homework or other tasks
12. Problems sticking with schoolwork or chores until they are done
TOTAL SCORE:
13. Puts off homework or chores until the last minute

14. Difficulty setting aside fun activities in order to start homework
15. Needs many reminders to start chores
TOTAL SCORE:
16. Trouble planning for big assignments (knowing what to do first, second, etc.?
17. Difficulty setting priorities when has a lot of things to do
18. Becomes overwhelmed by long-term projects or big assignments
TOTAL SCORE:
19. Backpack and notebooks are disorganized

20. Desk or workspace at home or school is a mess
21. Trouble keeping bedroom or locker tidy
TOTAL SCORE:
(cont.)

Executive Skills Questionnaire for Parents/Teachers (page 2 of 2)
Item Score
22. Has a hard time estimating how long it takes to do something (such as homework?
23. Often doesn’t finish homework at night; rushes to get it done in school before class
24. Slow getting ready for things (e.g., appointments, school, changing classes?
TOTAL SCORE:
25. If the first solution to a problem doesn’t work, has trouble thinking of a different one
26. Resists changes in plans or routines
27. Has problems with open-ended homework assignments (e.g., doesn’t know what to write
about when given a creative writing assignment?
TOTAL SCORE:
High School Students Only

28. Lacks effective study strategies
29. Doesn’t check work for mistakes even when the stakes are high
30. Doesn’t evaluate performance and change tactics in order to increase success
TOTAL SCORE:
31. Can’t seem to save up money for a desired object; problems delaying gratification
32. Doesn’t see the value in earning good grades to achieve a long-term goal
33. Seems to live in the present
TOTAL SCORE:
KEY
Items Executive Skill Items Executive Skill

1–3 Response inhibition 4–6 Working memory
7–9 Emotional control 10–12 Sustained attention
13–15 Task initiation 16–18 Planning/prioritization
19–21 Organization 22–24 Time management
25–27 Flexibility 28–30 Metacognition
31–33 Goal-directed persistence
Child’s Executive Skills Strengths Child’s Executive Skills Weaknesses

Form 2.5
Executive Skills Questionnaire for Students

Big problem 1
Moderate problem 2
Mild problem 3
Slight problem 4
No problem 5
Item Score
1. I act on impulse.
2. I get in trouble for talking too much in class.
3. I say things without thinking.
TOTAL SCORE:
4. I say, “I’ll do it later” and then forget about it.

5. I forget homework assignments or forget to bring home needed materials.
6. I lose or misplace belongings such as coats, notebooks, sports equipment, etc.
TOTAL SCORE:
7. I get annoyed when homework is too hard or confusing or takes too long to finish.
8. I have a short fuse; am easily frustrated.
9. I get upset easily when things don’t go as planned.
TOTAL SCORE:
10. I have difficulty paying attention and am easily distracted.

11. I run out of steam before finishing my homework.
12. I have problems sticking with chores until they are done.
TOTAL SCORE:
13. I put off homework or chores until the last minute.

14. It’s hard for me to put aside fun activities in order to start homework.
15. I need many reminders to start chores.
TOTAL SCORE:
16. I have trouble planning for big assignments (knowing what to do first, second, etc.?
17. It’s hard for me to set priorities when I have a lot of things to do.
18. I become overwhelmed by long-term projects or big assignments.
TOTAL SCORE:
19. My backpack and notebooks are disorganized.

20. My desk or workspace at home is a mess.
21. I have trouble keeping bedroom tidy.
TOTAL SCORE:
(cont.)
Copyright 2010 by Peg Dawson and Richard Guare. From Dawson and Guare (2010, The Guilford Press. Permission to
photocopy this form is granted to purchasers of this book for personal use only (see copyright page for details).

Executive Skills Questionnaire for Students (page 2 of 2)
Item Score
22. I have a hard time estimating how long it takes to do something (such as homework?
23. I often don’t finish homework at night and rush to get it done in school before class.
24. I’m slow getting ready for things (e.g., school or appointments?
TOTAL SCORE:
25. If the first solution to a problem doesn’t work, I have trouble thinking of a different one.
26. It’s hard for me to deal with changes in plans or routines.
27. I have problems with open-ended homework assignments (e.g., doesn’t know what
to write about when given a creative writing assignment?
TOTAL SCORE:
High School Students Only

28. I don’t have effective study strategies.
29. I don’t check my work for mistakes even when the stakes are high.
30. I don’t evaluate my performance and change tactics in order to increase success.
TOTAL SCORE:
31. I can’t seem to save up money for a desired object.

32. I don’t see the value in earning good grades to achieve a long-term goal.
33. If I should be studying and something fun comes up, it’s hard for me
to make myself study.
TOTAL SCORE:
KEY
Items Executive Skill Items Executive Skill

1–3 Response inhibition 4–6 Working memory
7–9 Emotional control 10–12 Sustained attention
13–15 Task initiation 16–18 Planning/prioritization
19–21 Organization 22–24 Time management
25–27 Flexibility 28–30 Metacognition
31–33 Goal-directed persistence
Your Executive Skills Strengths Your Executive Skills Weaknesses

Form 3.1
Executive Skills: Planning Interventions
Student Name: Date:

I. Data Sources—check all that apply

Parent Interview Parent Checklists Classroom Observation
Teacher Interview Teacher Checklists Work Samples
Student Interview Student Checklists Formal Assessment
II. Areas of Need—fill in applicable sections
Response Inhibition (RI): The capacity to think before acting
Specific problem behaviors (e.g., talks out in class; interrupts; says things without thinking)
1.
2.
3.
Working Memory (WM): The ability to hold information in memory while performing complex tasks
Specific problem behaviors (e.g., forgets directions; leaves homework at home; can’t do mental
arithmetic)
1.
2.
3.
Emotional Control (EC): The ability to manage emotions in order to achieve goals, complete tasks,
or control or direct behavior
Specific problem behaviors (e.g., “freezes” on tests; gets frustrated when makes mistakes; stops
trying in the face of challenge)
1.
2.
3.
Sustained Attention (SA): The capacity to maintain attention to a situation or task in spite of
distractibility, fatigue, or boredom
Specific problem behaviors (e.g., fails to complete classwork on time; stops work before finishing)
1.
2.
3.
(cont.)

Executive Skills: Planning Interventions (page 2 of 5)
Task Initiation (TI): The ability to begin projects without undue procrastination, in an efficient or
timely fashion
Specific problem behaviors (e.g., needs cues to start work; puts off long-term assignments)
1.
2.
3.
Planning/Prioritization (P): The ability to create a roadmap to reach a goal or to complete a task
Specific problem behaviors (e.g., doesn’t know where to start an assignment; can’t develop a
timeline for long-term assignments)
1.
2.
3.
Organization (O): The ability to create and maintain systems to keep track of information or
materials
Specific problem behaviors (e.g., doesn’t write down assignments; loses books or papers)
1.
2.
3.
Time Management (TM): The capacity to estimate how much time one has, how to allocate it, and
how to stay within time limits and deadlines
Specific problem behaviors (e.g., doesn’t work efficiently; can’t estimate how long it takes to do
something)
1.
2.
3.
Goal-Directed Persistence (GDP): The capacity to have a goal, follow through to the completion of
the goal, and not be put off by or distracted by competing interests
Specific problem behaviors (e.g., doesn’t see connection between homework and long-term goals;
doesn’t follow through to achieve stated goals)
1.
2.
3.
(cont.)

Flexibility (F): The ability to revise plans in the face of obstacles, setbacks, new information, or
mistakes; it relates to an adaptability to changing conditions
Specific problem behaviors (e.g., gets stuck on one problem-solving strategy; gets upset by
unexpected changes to schedule or plans)
1.
2.
3.
Metacognition (M): The ability to stand back and take a bird’s-eye view of oneself in a situation; the
ability to self-monitor and self-evaluate
Specific problem behaviors (e.g., doesn’t have effective study strategies; difficulty catching or
correcting mistakes)
1.
2.
3.
III. Establish Goal Behavior—select specific skill to work on
GOAL BEHAVIOR 1
Target Executive Skill:
Specific Behavioral Objective:

IV. Design Intervention
What environmental supports or modifications will be provided to help reach the target goal?
(cont.)

What specific skills will be taught, who will teach skill, and what procedure will be used to teach the
skill(s)?
Skill:
Who will teach skill:
Procedure:
Skill:
Who will teach skill:
Procedure:
What incentives will be used to help motivate the student to use/practice the skill(s)?
How Will the outcome be measured?
V. Evaluate Intervention
Review date:
Was the behavioral objective met? Yes, completely: Yes, partially: No:

(cont.)

Assessment of efficacy of intervention components:
Environmental Supports/Modifications
Were they put in place?
Were they effective?
Do they need to be continued?
Plan for fading supports:
Skill Instruction
Was the instruction implemented?
What was the outcome?
Does the instruction need to be continued?
Plan for fading instruction:
Incentives
Were incentives used?
Were they effective?
Do they need to be continued?
Plan for fading incentives:
Date for next review:

Form 4.1
Forms for Developing Behavior Plans/Incentive Systems

A. Incentive Planning Sheet
Problem Behavior
Goal
Possible Rewards
Daily Weekly Long Term
Possible Contingencies
(cont.)

Forms for Developing Behavior Plans/Incentive Systems (page 2 of 2)
B. Contract
Child agrees to:

To help child reach goal, parents or teacher(s) will:

hild will earn:

C

If child fails to meet agreement, child will:

Form 4.2
Executive Skills Self-Management Checklist

Check if
included in
Element What does student participation look like? intervention
Selection of target Student helps identify what behavior problem needs to be

behavior addressed.
Definition Student involved in developing operational definition of the

target behavior (e.g., “keep hands to self during circle time”).
Selection of primary Student is asked to identify possible reinforcers; helps create

reinforcers a reinforcement menu.
Performance goal Student helps set a reasonable goal for the target behavior
(e.g., “Remember to raise my hand x% of the time”).
Instructional prompt Student helps decide the best way to remember to prompt for
the behavior (e.g., use of kitchen timer or random self-cuing
for on-task behavior).
Observation Student is responsible for monitoring the target behavior.
Recording Ask student best way to record the presence or absence of

the target behavior.
Evaluation Student is at least partially responsible for determining

when the goal was met (may include a system for verifying
accuracy).
Administration of Student gives him- or herself points or tokens for exhibiting

secondary reinforcers target behavior.
Administration of When the student has accumulated enough points or tokens,

primary reinforcers he or she chooses reward from reinforcement menu.
Monitoring Student is responsible for charting or graphing performance

over time.
Based on Briesch and Chafouleas (2009). From Dawson and Guare (2010). Copyright by The Guilford Press. Permission to
photocopy this form is granted to purchasers of this book for personal use only (see copyright page for details).

Form 4.3
Getting to Know You
Name:
1. How do you spend your spare time? Check (v) all that apply and draw a circle around your favorite
three activities.
 with family  TV/DVDs  reading  theater/dance  part-time job
 with friends  alone  sports  Internet, IM  video/computer games
 outdoors  sleeping  writing  listening to music  volunteering
 arts, crafts, building things  playing an instrument  extracurricular activities at school
 dirt biking/four-wheeling  OTHER:
2. What talents do you have? Check all that apply and provide an example if you can.
 Athletic:  Artistic:
 Musical:  Writing:
 Communication:  Leadership:
 Performing arts:  Technology:
 Mechanical skills:  Math/sciences:
 Cooking, sewing:  Interpersonal skills:
 OTHER:
3. What personal qualities do you have that you consider to be strengths? Check up to five.
 leadership  patience  creativity  sense of humor  independence
 caring, empathy  hard worker  loyalty  imagination  dependability
 determination  optimism  self-control  coping skills  problem solving
 persistence  ambition  honesty  organization  courage
 competitiveness  extraversion (outgoing)  working well with others
 OTHER:
4. What areas of skill or knowledge would you like to become an expert in? List any topic that
interests you, even if it is something you don’t usually learn about in school (e.g., skateboarding,
video games, sports statistics, cheerleading, horseback riding).
(cont.)

Getting to Know You (page 2 of 2)
5. How do you learn best? Check all that apply.

a. Group size:
alone  small group (2–4 people)

 medium group (5–7 people)  whole class
b. Learning style:
visual  hands on

listening  memorizing

 discussion  activity/experiential learning
 apprenticeship  taking notes
reading  thinking about what I’ve read or heard

 OTHER:
c. What is your preferred study environment?

library  study hall at school

bedroom  other room in my house

 with friends  public place (e.g., coffee shop)
 resource room  OTHER:
6. What are your preferred classroom activities? Check all that apply.
 lecture  discussions  projects
 debates  group games  presentations
 reading  creative writing  worksheets
 labs/experiments  cooperative learning  brainstorming
 outdoor activities field trips  learn, then teach others

 role playing  simulations  taking tests
 self-directed learning  individual research  doing homework
 movies/DVDs  working on the computer  teacher-led instruction
 doodling  daydreaming  talking with friends
 OTHER:

Form 5.1
Morning Routine Checklist

Check
Task When Done
Hang up coats/outerwear in appropriate place
Get out homework and place on right upper corner of desk
Sharpen pencils and gather other materials needed for the first class
Check the blackboard for instructions
Follow instructions

Form 5.2
End-of-Day Routine Checklists

End-of-Day Routine—Checklist 1
Packed
Materials needed in bag
Assignment book filled in
Spelling workbook
Reading book
Reading folder
Social studies book
Social studies folder
Science book
Science folder
Math book
Math folder
Other (permission slips, notices, etc.):
Signed: Date:

(cont.)

End-of-Day Routine Checklists (page 2 of 2)
End-of-Day Routine—Checklist 2
Check When
Steps to Follow Done
Hand in any homework assignments completed
Hand in any in-class assignments completed
Return any materials borrowed from classmates or teacher
Tidy up desk surface; check floor around desk
Gather all necessary materials to go home

1—Books
2—Notebooks
3—Folders
4—Assignment book
5—Worksheets
6—Slips/notices for parents
7—Clothing (hat, mittens, coat)
8—Gym clothes
9—Other
Place appropriate materials in backpack
Ask myself, Am I forgetting anything?

Form 5.3

Daily Homework Planner
Date:
Do I have all the How long do you How long did

Subject/assignment materials? Do I need help? think it will take? Start time Stop time it take?
Yes No Yes No
   
Yes No Yes No
   
Yes No Yes No
   

Yes No Yes No
   
Yes No Yes No
   
Yes No Yes No
   
From Dawson and Guare (2010). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this book for personal use only (see copyright page
for details).
Form 5.4
Attention-Monitoring Checklist
Date:
Time:
Class activity:
Was I paying attention?
YES NO

Form 5.5
Desk Cleaning Checklist

STEP 1: GATHER NECESSARY MATERIALS
Check all
Materials needed that apply
Wastebasket
Empty file folders
Three-ring binders
Paper clips
Stapler
Manila envelopes
STEP 2: FOLLOW DESK-CLEANING PROCEDURE
Check
Procedure when done
Empty out desk.
Sort everything into two piles: Save/Don’t Save.
Throw Don’t Save pile in wastebasket.
Sort Save Pile into two piles:

1. School stuff (books, unfinished assignments, assignments that are completed but
the teacher wants me to save, pens, pencils, etc.)
2. Home stuff (notices/slips to give Mom, assignments I want to save but don’t have
to keep for teacher, uneaten snacks, etc.)
Put “home stuff” in backpack to go home (in folders or manila envelopes if necessary).
Sort school stuff: one pile for incomplete homework assignments, one pile for each
subject (not current homework), one extra pile for “other.”
Organize each subject pile following teacher instructions (e.g., placing materials by
date in three-ring binders or folders).
Decide what to do with the “other” pile.
Put all school materials neatly back in desk.

Form 5.6
Writing Template for a Five-Paragraph Essay

Introductory Paragraph
Sentence 1 summarizes what your essay is about:
Sentence 2 focuses in on the main point you want to make:
Sentence 3 adds more detail or explains why the topic is important:
Body Paragraphs
Paragraph 1, topic sentence:
Supporting detail 1:
(cont.)

Writing Template for a Five-Paragraph Essay (page 2 of 2)
Concluding Paragraph
Restate the most important point from the paper you want to make (what the reader should
go away understanding):

Form 5.7
Long-Term Project-Planning Sheet

STEP 1: SELECT TOPIC
What are possible topics? What I like about this choice: What I don’t like:
1.
2.
3.
4.
5.
Final Topic Choice:
STEP 2: IDENTIFY NECESSARY MATERIALS
What materials or resources

do you need? Where will you get them? When will you get them?
1.
2.
3.
4.
5.
(cont.)

Long-Term Project-Planning Sheet (page 2 of 2)
STEP 3: IDENTIFY PROJECT TASKS AND DUE DATES
When will you Check off

What do you need to do? (List each step in order) do it? when done
Step 1:
Step 2:
Step 3:
Step 4:
Step 5:
Step 6:
Step 7:
Step 8:
Step 9:
Step 10:
Reminder List
Include here any additional tasks or details you need to keep in mind as you work on the project. Cross
out or check off each one as it is taken care of.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Form 5.8
Tools for Studying

A. Menu of Study Strategies
Check off the ones you will use.
1. Reread text 8. Make concept maps 15. Create a “cheat sheet”
2. Reread/organize notes 9. Make lists/organize 16. Study with friend
3. Read/recite main points 10. Take practice test 17. Study with study group
4. Outline text 11. Quiz myself 18. Study session with teacher
5. Highlight text 12. Have someone else quiz me 19. Study with a parent
6. Highlight notes 13. Study flash cards 20. Ask for help
7. Use study guide 14. Memorize/rehearse 21. OTHER:
B. Study Plan
Date Day Which strategies will I use? (write #) How much time for each strategy?
4 days 1. 1.
before test 2. 2.
3. 3.
3 days 1. 1.
before test 2. 2.
3. 3.
2 days 1. 1.
before test 2. 2.
3. 3.
1 day 1. 1.
before test 2. 2.
3. 3.
C. Posttest Evaluation
How did your studying work out? Answer the following questions:
1. What strategies worked best?

2. What strategies were not so helpful?
3. Did you spend enough time studying? Yes No
4. If no, what more should you have done?
5. What will you do differently the next time?

Form 5.9
Organizing Notebooks/Homework
A. Setting Up a Notebook/Homework Management System
Got it
System element What will you use? ()
Place for unfinished

homework
Place for completed

assignments
Place to keep materials for

later filing
Notebooks or binder(s) for

each subject
Other things you might need:

1.
2.
3.
4.
B. Maintaining a Notebook/Homework Management System
Task Monday Tuesday Wednesday Thursday Weekend
Clean out “to be filed” folder
Go through notebooks and

books for other loose papers
and file them
Place all assignments (both

finished and unfinished) in
appropriate places

Form 5.10
Note-Taking Template: Cornell Method
Date: Class:

Lecture Topic:
Reflections, questions, links

Key terms and concepts Running notes to personal experience

Form 5.11
Hard Times Board

Triggers: What makes me mad
Can’t dos
When I’m having a hard time, I can take a break and

Form 5.12
Maintaining Self-Control
The things I do without thinking include
Common situations where I act without thinking are
What I will do to stay controlled

Form 5.13
Worry Board
I get worried when . . .
When I get nervous . . .
When I’m feeling nervous I can . . .

Form 5.14
Managing Changes in Plans or Schedules

A. Surprise! Card
Date:
Time Activity
Surprise:
B. Complaint Form
Date:
Nature of Complaint:
Why You Think the Situation Was Unfair:
What You Wish Had Happened:

Form 5.15
Learning Not to Cry over Little Things

A. Upset Log
Date Time Duration of upset Precipitating event
B. Contract
Here’s what I can do instead of crying:
Here’s what will happen if I can keep from crying when I’m upset:
Here’s what will happen when I cry over little things:

Form 5.16
Solving Problems Worksheet

What is the problem?
What are some possible things I (we) could do to solve the problem?
What will I (we) try first?
If this doesn’t work, what can I (we) do?
How did it go? Did my (our) solution work?
What might I (we) do differently the next time?

Form 8.1

Progress Monitoring: Response to Intervention
Student’s Name:
Tier Start Review Measurement

level Intervention date date Criterion for success procedure Outcome Next step

From Dawson and Guare (2010). Copyright by The Guilford Press. Permission to photocopy this form is granted to purchasers of this book for personal use only (see copyright page
for details).

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Executive Skills in Children and Adolescents, 2nd edition

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Executive Skills Semistructured Interview—Parent Version

Understanding homework directions

Getting started on his or her own (TI)

Being able to keep working despite

Asking for help when it’s needed (M)

Sticking with it long enough to

Making careless mistakes; failing to

Finishing the work on time (TM)

Remembering to hand it in (WM)

More likely to be successful with . . . Less likely to be successful with . . .

Keeping notebooks and papers organized (O)

Keeping desk tidy (O)

Keeping belongings neat and in appropriate locations

Keeping track of books, papers, pencils, etc. (O)

Keeping backpack organized (O)

Deciding on a topic (P)

Breaking the assignment into smaller parts (P)

Developing a timeline (P)

Following a timeline (TM)

Estimating how long it will take to finish (TM)

Following directions carefully (WM, M)

Proofreading or checking project to catch mistakes

Finishing the project by the deadline (GDP)

Writing down assignments (WM

Bringing home appropriate materials (e.g., books,

Bringing to school appropriate materials (see

Remembering instructional sequences after

Remembering to perform chores or other

Losing things within the home, yard, or

Recognizing that he or she has a problem (e.g.,

Being able to think flexibly about the problem (e.g.,

Trying to solve the problem first on his or her own

Accessing appropriate resources to help him or her

Evaluating his or her own performance to know

Becoming easily upset (EC)

Throwing temper tantrums (EC)

Acting impulsively, either verbally or

Interrupting others (RI)

Difficulty waiting turn (RI)

Executive Skills Semistructured Interview—Teacher Version

Understanding task directions (M)

Getting started on his or her own (TI)

Being able to keep working despite distractions (SA)

Asking for help when it’s needed (M)

Sticking with it long enough to complete it (SA, GDP)

Making careless mistakes; failing to check work (M)

Finishing the work on time (TM)

Remembering to hand it in (WM)

More likely to be successful with . . . Less likely to be successful with . . .

Keeping notebooks and papers organized (O)

Keeping desk tidy (O)

Keeping belongings neat and in appropriate locations

Keeping track of books, papers, pencils, etc. (O)

Keeping backpack organized (O)

Deciding on a topic (P)

Breaking the assignment into smaller parts (P)

Developing a timeline (P)