Jack Barker Executive Functioning Survey - 5/2022
Name: 


  1. Planning and Organizing
    1 - Poor: Student does not indpendently plan and organize information needed to complete tasks.
    2 - Fair: Student is able to plan and organize information needed to complete tasks with support from special education staff.
    3 - Good: Student is almost always able to plan and organize information needed to complete tasks.
    4 - Excellent:Student consistently plans and organizes information needed to complete tasks


  1. Communication: independently approaches teachers to clarify expectations.
    1 - Poor: Student does not approach teacher to clarify expectations.
    2 - Fair:Student approaches teachers to clarify expectations only when required to by special education staff or parent.
    3 - Good:Student approaches teachers to clarify expectations with support from the Special Education staff.
    4 - Excellent: Student independently approaches teachers to clarify expectations.


  1. Execution and Goal Attainment: Takes extra measures to ensure work is completed and turned in 100% of the time.
    1 - Poor: Student consistently has missing work. Student does not pursue turning in missing work.
    2 - Fair:Student turns work in late. Student requires prompts from staff or parents to turn in missing work.
    3 - Good:Student turns in work on time 75-100% of the time. Student requires minimal prompts to turn work in.
    4 - Excellent: Completes and turns in work accurately 100% of the time. Promptly arranges for and completes work after an absence.





Christie Mead
Harmony Middle School
KS