Ages and Stages Report Form

Childs Name: M ___________ Date of Birth___11/21/11_______

Date of Examination ____3/17/16__________ Date of Report_____3/19/16________
Chronological Age _______4 year 3 months 28 days___________________________
Examiners Name ________Mackenzie Gough_______________________________
Name(s) of Assessment___ASQ-3_____
Name(s) of Other Assessment Procedures ____None__________________________

Reason for Referral:

ECE 362 Class Assignment

Background Information:
DETAILS & DEMOGRAPHICS!!!!! You MUST provide ample details about the child, their family,
home life, and current and past educational experiences. Think.ELS? Socio-economic status, rural life-city
life, family makeup and dynamics, hobbies, experiences, and on and on think of how much these things impact
development.
M is the youngest child in a household with her mother (Ekartina), Father (Alexander) and sister. Her
mother is an instructor at SDSU. Her sister is a second grader. M is Russian and can speak both Russian and
English. She is currently enrolled in preschool in the morning at Peace Lutheran and in the afternoon at SDSU
in Emmas three and four year old classroom. I would guess that M is middle class, and lives in the city limits
of Brookings. She enjoys listening to books, doing science experiments and playing games like I spy.
Behavioral Observations:
Not only do you need to fill out the behavioral observations on the protocol, you need to translate that in
written words here. Complete sentences, elaborate, give details that will paint a picture of why the student may
or may not have performed to the best of their ability. Remember how context and rapport can greatly impact
assessment outcomes.
M completed most of the tasks with ease, she did not hesitate or struggle getting to the solution. The
only section of the questionnaire that M struggled with was the gross motor potion. When working with M in
the large motor room she struggled catching a large ball with both hands, throwing a ball overhand and jumping
forward with both feet. For example, when I would throw the ball for M to catch she caught the ball with both
hands two out of the ten times. I believe that action was difficult because it is an exercise that M is unfamiliar
with. I also observed M trying to throw a ball overhand to me and she did not always use overhand and would
resort to underhand. M also switched back and forth from using both feet together when jumping forward with
one foot for the fifth potion of the gross motor section. I reminded her to jump like a bunny and that seemed to
improve her results. Overall, I believe M lower scores (compared to her perfect scores in other sections) are a
result of lack of practicing her gross motor skills as well as not feeling out of her comfort zone.
Assessment Results:
You must provide the official Ages and Stages results here (normal, suspect, rescreen, or untestable)
but you must also provide verbiage to support the findings. DETAILS again darn it!
Ms results to the Ages and Stages questionnaire are normal or are show that her development appears to be
on schedule. Her scores for communication, fine motor, problem solving, and personal-social were all 60 and
her score for gross motor score was 45, all above the cutoff. These results do not surprise me as M is very

successful in activates in the classroom and has shown that she is advanced in different skills such as math
communication, and fine motor.
Recommendations:
Even if the child is screened normal you can elaborate on how continuing their current course of
education will benefit their development. If you have delays or cautions, please note what they are and what
specific activities a family could do to address these areas of development put them in the
positive/negative/positive sandwich approach.
M screened normal in all areas of the Ages and Stages questionnaire. Therefore, I recommend that she
continue her current course of education at the SDSU lab school because it will allow her to keep her childhood
development on track by practicing and further developing her communication, gross motor, fine motor,
problem solving and personal-social skills through daily lessons and activities. I would also encourage teacher
and parents that are working with M to focus on getting M comfortable with gross motor activities so that she
can improve her skills.
Self-Evaluation of Testing:
Duh! Evaluate how you think this experience went. What could you have done differently or the same?
How is the experience beneficial to you?
This was a new experience for me and I enjoyed seeing where M was at with certain skills and how I
(and other teachers) can improve instruction to aid in appropriate child development. I also found it most
beneficial to spread out the days of questioning M so that she was not get tired or board. The only part that I
found difficult was communicating with her parents about returning the questionnaire that was completed at
home. Her father is typically the parent that drops off and picks up and I do not believe he understood what I
was saying when explaining the process of the Ages and Stages Questionnaire. I believe the language barrier
delayed the process of returning the questionnaire because as soon as I sent an email to her mother the
questionnaire was returned in a few days. Therefore, next time if there is a delay in response I will be quicker to
send an email reminder.