CCITSN Forms
CCITSN Forms
This download includes one PDF of the Carolina Curriculum Assessment Logs and
Developmental Progress Charts. You may print this PDF in its entirety or by select-
ing specific pages; the Contents (below) provides the page numbers corresponding to
the Assessment Log and Developmental Progress Chart. You may save this PDF on a
computer and/or post on an internal network accessible only by employees at a sin-
gle site so that the employees may print the PDF as needed.
Assessment Log
and Developmental
Progress Chart
______________________________________________________________
______________________________________________________________
DIRECTIONS:
Assessment Log: Insert the date of your assessment at the top of the column and insert a + in the box for
each mastered item, a +/– for an inconsistent or emerging skill, and a – for a skill the child is unable to
do. When working with a child with severe motor impairments, it is useful to add an A alongside the + or
+/– to indicate that the child accomplished the task with physical assistance.
Developmental Progress Chart: Each item on the Assessment Log is represented by a square on the
Developmental Progress Chart. Using a highlighter or other colored writing instrument, fill in the squares
associated with items marked with a +. Make a diagonal line through squares associated with items marked
with a +/– and color them in halfway. Those marked with a – should be left blank. Complete the chart by
filling in the squares preceding the age span in which all items were passed. When working with a child
with severe motor impairments, it is useful to add an A to the box to indicate that the child accomplished
the task with physical assistance.
The Carolina Curriculum for Infants and Toddlers with Special Needs, Third Edition, by Nancy M. Johnson-Martin,
Susan M. Attermeier, & Bonnie J. Hacker.
© 2004 Paul H. Brookes Publishing Co., Inc. All rights reserved.
CONTENTS
ASSESSMENT LOG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1
Personal–Social
1. Self-Regulation & Responsibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2. Interpersonal Skills . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
3. Self-Concept . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
4-I. Self-Help: Eating . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
4-II. Self-Help: Dressing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
4-III. Self-Help: Grooming . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
4-IV. Self-Help: Toileting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Cognition
5. Attention & Memory: Visual/Spatial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
6-I. Visual Perception: Blocks & Puzzles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
6-II. Visual Perception: Matching & Sorting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
7. Functional Use of Objects & Symbolic Play . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
8. Problem Solving/Reasoning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
9. Number Concepts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Cognition/Communication
10. Concepts/Vocabulary: Receptive . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
11. Concepts/Vocabulary: Expressive . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11
12. Attention & Memory: Auditory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11
Communication
13. Verbal Comprehension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12
14. Conversation Skills . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13
15. Grammatical Structure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15
16. Imitation: Vocal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15
Fine Motor
17. Imitation: Motor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16
18. Grasp & Manipulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16
19. Bilateral Skills . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17
20. Tool Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18
21. Visual-Motor Skills . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19
Gross Motor
22-I. Upright: Posture & Locomotion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19
22-II. Upright: Balance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
22-III. Upright: Ball Play . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
22-IV. Upright: Outdoor Play . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
23. Prone (on Stomach) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
24. Supine (on Back) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
The Carolina Curriculum for Infants and Toddlers with Special Needs, Third Edition, by Nancy M. Johnson-Martin,
Susan M. Attermeier, & Bonnie J. Hacker.
©
2004 Paul H. Brookes Publishing Co., Inc. All rights reserved.
ASSESSMENT
Insert the date of your assessment at the LOGa + in the box for each mastered item.
top of the column and insert
Progress for all four assessments is charted on one Developmental Progress Chart (see pages 24–25) with each
assessment written in a different color.
Personal–Social
Personal–Social
1. Self-Regulation & Responsibility
0–3 a. Stops crying when sees or touches bottle or breast
k. Explores
21–24 l. Tolerates being taken into
a variety of environments
2. Interpersonal Skills
0–3 a. Smiles to auditory and tactile stimulation
b. Smiles reciprocally
The Carolina Curriculum for Infants and Toddlers with Special Needs, Third Edition, by Nancy M. Johnson-Martin,
Susan M. Attermeier, & Bonnie J. Hacker.
© 2004 Paul H. Brookes Publishing Co., Inc. All rights reserved.
Age Date: Date: Date: Date:
(months) Curriculum Sequences Notes:
m. Shows affection
3. Self-Concept
9–12 a. Responds to name
The Carolina Curriculum for Infants and Toddlers with Special Needs, Third Edition, by Nancy M. Johnson-Martin,
Susan M. Attermeier, & Bonnie J. Hacker.
© 2004 Paul H. Brookes Publishing Co., Inc. All rights reserved.
Age Date: Date: Date: Date:
(months) Curriculum Sequences Notes:
l. Shows determination/persistence in
choosing or continuing activities
4-I. Self-Help
Self-Help:Skills:
EatingEating
0–3 a. Smoothly sucks from nipple
q. Chews well
Self-Help:Skills:
4-II. Self-Help Dressing
Dressing
9–12 a. Cooperates in dressing and undressing
f. Puts on hat
i. Removes coat
Self-Help:Skills:
4-III. Self-Help Grooming
Grooming
6–9 a. Enjoys playing in water
The Carolina Curriculum for Infants and Toddlers with Special Needs, Third Edition, by Nancy M. Johnson-Martin,
Susan M. Attermeier, & Bonnie J. Hacker.
© 2004 Paul H. Brookes Publishing Co., Inc. All rights reserved.
Age Date: Date: Date: Date:
(months) Curriculum Sequences Notes:
Self-Help:Skills:
4-IV. Self-Help Toileting
Toileting
15–18 a. Indicates need for soiled diaper
or pants to be changed
Cognition
Personal–Social
The Carolina Curriculum for Infants and Toddlers with Special Needs, Third Edition, by Nancy M. Johnson-Martin,
Susan M. Attermeier, & Bonnie J. Hacker.
© 2004 Paul H. Brookes Publishing Co., Inc. All rights reserved.
Age Date: Date: Date: Date:
(months) Curriculum Sequences Notes:
The Carolina Curriculum for Infants and Toddlers with Special Needs, Third Edition, by Nancy M. Johnson-Martin,
Susan M. Attermeier, & Bonnie J. Hacker.
© 2004 Paul H. Brookes Publishing Co., Inc. All rights reserved.
Age Date: Date: Date: Date:
(months) Curriculum Sequences Notes:
Blocks &&Puzzles
6-I. Visual Perception: Puzzles Blocks
12–15 a. Places large round form in form board
Perception: Matching&&Sorting
6-II. Visual Perception:Matching Sorting
24–30 a. Sorts by size (big and little)
c. Sorts by shape
The Carolina Curriculum for Infants and Toddlers with Special Needs, Third Edition, by Nancy M. Johnson-Martin,
Susan M. Attermeier, & Bonnie J. Hacker.
© 2004 Paul H. Brookes Publishing Co., Inc. All rights reserved.
Age Date: Date: Date: Date:
(months) Curriculum Sequences Notes:
8. Problem Solving/Reasoning
0–3 a. Shifts attention (i.e., visual fixation, body
orientation) from one object to another
The Carolina Curriculum for Infants and Toddlers with Special Needs, Third Edition, by Nancy M. Johnson-Martin,
Susan M. Attermeier, & Bonnie J. Hacker.
© 2004 Paul H. Brookes Publishing Co., Inc. All rights reserved.
Age Date: Date: Date: Date:
(months) Curriculum Sequences Notes:
9. Number Concepts
21–24 a. Understands “more” as an addition
to some existing amount
The Carolina Curriculum for Infants and Toddlers with Special Needs, Third Edition, by Nancy M. Johnson-Martin,
Susan M. Attermeier, & Bonnie J. Hacker.
© 2004 Paul H. Brookes Publishing Co., Inc. All rights reserved.
Age Date: Date: Date: Date:
(months) Curriculum Sequences Notes:
Cognition/Communication
10. Concepts/Vocabulary:
10. Concepts/Vocabulary: Receptive
Receptive
The Carolina Curriculum for Infants and Toddlers with Special Needs, Third Edition, by Nancy M. Johnson-Martin,
Susan M. Attermeier, & Bonnie J. Hacker.
© 2004 Paul H. Brookes Publishing Co., Inc. All rights reserved.
Age Date: Date: Date: Date:
(months) Curriculum Sequences Notes:
11. Concepts/Vocabulary:
11. Concepts/Vocabulary: Expressive
Expressive
6–9 a. Vocalizes repetitive consonant–vowel combinations
The Carolina Curriculum for Infants and Toddlers with Special Needs, Third Edition, by Nancy M. Johnson-Martin,
Susan M. Attermeier, & Bonnie J. Hacker.
© 2004 Paul H. Brookes Publishing Co., Inc. All rights reserved.
Age Date: Date: Date: Date:
(months) Curriculum Sequences Notes:
Communication
13. Verbal Comprehension
0–3 a. Appropriately reacts to tone of voice
and/or some facial expressions
The Carolina Curriculum for Infants and Toddlers with Special Needs, Third Edition, by Nancy M. Johnson-Martin,
Susan M. Attermeier, & Bonnie J. Hacker.
© 2004 Paul H. Brookes Publishing Co., Inc. All rights reserved.
Age Date: Date: Date: Date:
(months) Curriculum Sequences Notes:
e. Laughs
The Carolina Curriculum for Infants and Toddlers with Special Needs, Third Edition, by Nancy M. Johnson-Martin,
Susan M. Attermeier, & Bonnie J. Hacker.
© 2004 Paul H. Brookes Publishing Co., Inc. All rights reserved.
Age Date: Date: Date: Date:
(months) Curriculum Sequences Notes:
The Carolina Curriculum for Infants and Toddlers with Special Needs, Third Edition, by Nancy M. Johnson-Martin,
Susan M. Attermeier, & Bonnie J. Hacker.
© 2004 Paul H. Brookes Publishing Co., Inc. All rights reserved.
Age Date: Date: Date: Date:
(months) Curriculum Sequences Notes:
16. Imitation:
16. Imitation: Vocal
Vocal
0–3 a. Quiets to voice
e. Imitates inflection
The Carolina Curriculum for Infants and Toddlers with Special Needs, Third Edition, by Nancy M. Johnson-Martin,
Susan M. Attermeier, & Bonnie J. Hacker.
© 2004 Paul H. Brookes Publishing Co., Inc. All rights reserved.
Age Date: Date: Date: Date:
(months) Curriculum Sequences Notes:
Fine Motor
17. Verbal
13. Imitation: Motor
Comprehension
0–3 a. Looks at caregiver and makes facial movements
when caregiver is talking or making noises
18.
18. Grasp
Grasp &
& Manipulation
Manipulation
0–3 a. Actively moves arm after seeing or hearing an object
The Carolina Curriculum for Infants and Toddlers with Special Needs, Third Edition, by Nancy M. Johnson-Martin,
Susan M. Attermeier, & Bonnie J. Hacker.
© 2004 Paul H. Brookes Publishing Co., Inc. All rights reserved.
Age Date: Date: Date: Date:
(months) Curriculum Sequences Notes:
The Carolina Curriculum for Infants and Toddlers with Special Needs, Third Edition, by Nancy M. Johnson-Martin,
Susan M. Attermeier, & Bonnie J. Hacker.
© 2004 Paul H. Brookes Publishing Co., Inc. All rights reserved.
Age Date: Date: Date: Date:
(months) Curriculum Sequences Notes:
u. Screws on lids
The Carolina Curriculum for Infants and Toddlers with Special Needs, Third Edition, by Nancy M. Johnson-Martin,
Susan M. Attermeier, & Bonnie J. Hacker.
© 2004 Paul H. Brookes Publishing Co., Inc. All rights reserved.
Age Date: Date: Date: Date:
(months) Curriculum Sequences Notes:
21.
21. Visual-Motor
Visual-Motor Skills
Skills
12–15 a. Marks paper with writing implement
g. Pretends to write
Gross Motor
22-I. Upright:
13. Verbal Posture & Locomotion
Comprehension
0–3 a. Holds head steady when held
d. Sits alone
The Carolina Curriculum for Infants and Toddlers with Special Needs, Third Edition, by Nancy M. Johnson-Martin,
Susan M. Attermeier, & Bonnie J. Hacker.
© 2004 Paul H. Brookes Publishing Co., Inc. All rights reserved.
Age Date: Date: Date: Date:
(months) Curriculum Sequences Notes:
q. Runs stiffly
r. Jumps on floor
22-II. Upright:
22-II. Upright: Balance
Balance
15–18 a. Stands on one foot while hands are held
The Carolina Curriculum for Infants and Toddlers with Special Needs, Third Edition, by Nancy M. Johnson-Martin,
Susan M. Attermeier, & Bonnie J. Hacker.
© 2004 Paul H. Brookes Publishing Co., Inc. All rights reserved.
Age Date: Date: Date: Date:
(months) Curriculum Sequences Notes:
22-III. Upright:
22-III. Upright: Ball
Ball Play
Play
The Carolina Curriculum for Infants and Toddlers with Special Needs, Third Edition, by Nancy M. Johnson-Martin,
Susan M. Attermeier, & Bonnie J. Hacker.
© 2004 Paul H. Brookes Publishing Co., Inc. All rights reserved.
Age Date: Date: Date: Date:
(months) Curriculum Sequences Notes:
The Carolina Curriculum for Infants and Toddlers with Special Needs, Third Edition, by Nancy M. Johnson-Martin,
Susan M. Attermeier, & Bonnie J. Hacker.
© 2004 Paul H. Brookes Publishing Co., Inc. All rights reserved.
DEVELOPMENTAL PROGRESS CHART
Dates
1. ____________________________________________ Child: ________________________________________________________________________________________________________________________
2. ____________________________________________ Interventionist: ________________________________________________________________________________________________________________
3. ____________________________________________
4. ____________________________________________
Curriculum Sequence 0–3 Months 3–6 Months 6–9 Months 9–12 Months 12–15 Months
1. Self-Regulation & Responsibility a b c d e f g h
2. Interpersonal Skills a b c d e f g h i j k l m
PERSONAL–SOCIAL
3. Self-Concept a b c
4-I. Self Help: Eating a b c d e f g h i j k l m n o
4-II. Self-Help: Dressing a b c
4-III. Self-Help: Grooming a b c
4-IV. Self-Help: Toileting
5. Attention & Memory: Visual/Spatial a b c d e f g h i j k l m n o p q r s
6-I. Visual Perception: Blocks & Puzzles a
COGNITION
The Carolina Curriculum for Infants and Toddlers with Special Needs, Third Edition, by Nancy M. Johnson-Martin, Susan M. Attermeier, & Bonnie J. Hacker.
© 2004 Paul H. Brookes Publishing Co., Inc. All rights reserved.
Curriculum Sequence 15–18 Months 18–21 Months 21–24 Months 24–30 Months 30–36 Months
1. Self-Regulation & Responsibility i j k l m l n o
2. Interpersonal Skills n o p q r s t u v w x y z aa bb
PERSONAL–SOCIAL
3. Self-Concept d e f g h i j k l m n o p q r s t
4-I. Self Help: Eating p q r s t u v w x y z
4-II. Self-Help: Dressing d e f g h i j k l
4-III. Self-Help: Grooming d e f g h i j
4-IV. Self-Help: Toileting a b c d e f g
5. Attention & Memory: Visual/Spatial t u v w x y z aa bb cc dd ee ff gg hh
6-I. Visual Perception: Blocks & Puzzles b c d e f g h i j k l m n
COGNITION
The Carolina Curriculum for Infants and Toddlers with Special Needs, Third Edition, by Nancy M. Johnson-Martin, Susan M. Attermeier, & Bonnie J. Hacker.
© 2004 Paul H. Brookes Publishing Co., Inc. All rights reserved.
About The
Carolina Curriculum
Brookes On Location is a program that connects you with the experts behind Brookes
books for seminars tailored to your agency’s specific needs. We offer you an outline of
the seminar, and you determine the venue for the seminar and the professional devel-
opment priorities for the participants.
After you contact Brookes about arranging a seminar, we share your request with the
speakers and make recommendations that will help you meet the needs of your staff.
Brookes then coordinates the speakers’ schedules to find a date that works for both of
you. (Please note that we cannot guarantee a speaker’s availability on a specific date.)
Seminars can range from a half-day to a whole week, depending on the subject and the
needs of your staff. The speaker’s fee varies depending on the seminar subject and
length and the number of participants. The total cost will include the speaker’s fee
and travel expenses as well as handouts for participants. Contact Brookes Publishing
at 410-337-9580 or visit www.brookespublishing.com/onlocation for more informa-
tion.
The seminar using the Carolina Curriculum presents an assessment and intervention
program for young children (birth to 5 years) with mild to severe disabilities.
Speaker
Co-author Susan M. Attermeier, Ph.D., PT, presents this seminar. She served on the
Physical Therapy Faculty at the University of North Carolina at Chapel Hill and is
currently in private practice. She obtained a bachelor’s degree in Physical Therapy
from Marquette University, a master’s degree in Education at the University of North
Carolina at Chapel Hill, and a Ph.D. in Special Education at the University of North
Carolina at Chapel Hill.
Recommended Materials
The Carolina Curriculum for Infants and Toddlers with Special Needs, Third Edition,
and/or The Carolina Curriculum for Preschoolers with Special Needs, Second Edition
The seminar can be targeted to the information and approaches necessary for work-
ing with children whose skills fall into any range from birth to 5.
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