Teacher Questionnaire RaiSCHOOL aaa | Y@ companion SENSORY PROFILE.2 Winnie Dunn, PhD, OTR, FAOTA ‘Student's First Name: ‘Student's Last Name: ‘Student's Preferred Name (if different from above}: Gender: Male Female Birth Date: _/ ‘Tosh Date: eae Examiner/Service Provider's Name: Examiner/Service Provider's Profession: Completed by/Teacher’s Name: Name of School/Daycare Center: Please estimate the frequency of contact you have with this student: 111 day/week (1 2days/week (13to4 days/week Dally Other How many years have you had contact with this student? Gmosoriess C7mostoty Otto2ys O2toSyrs OSto4yrs O4toSyrs CSyrsormore ‘The pages that follow contain statements that describe hovr students may act. Please read each phrase and select the Contion that best describes how often this student shows these behaviors, Please mark one option for every statement. Use these guidelines to mark your responses: When presented with the opportunity, this student... (ERE sesponds in this manner Almost Always (909% or more of he time. responds in this manner Frequently (75% of the time). responds in this manner Half the Time (50% of the tim). [SENT responds in this manner Occasionally 25% of the time). ~ 7 E responds in this manner Almost Never (10% or less of the time), | If you are unable to answer because you have not observed the behavior or believe ‘that it does not apply to this student, please check Does Not Apply. d PSSTAOIMDL | cccoetocacies Src capi len Voney nee locas en erapr ne COSTCO Does Not Apply 500.027.7271, wwrn-Pearsonclinical.com Copyright © 2014 NCS Pearson, In. All rights reserved. ‘Warning: No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, induding photocopy, recording, or any information storage and ‘eiaval system, wthaut permission in writing fom the copyright owner, Pearson, the PSI logo, PsychCorp, and Sensory Profile are trademarks in the U.S. and/or ter entries of Pearson Edueaton, Ine, oF te afMatets). Printed in the United States of America. 1234567891011 12ABCDE Prodst Number 01587000[Hae Tine = 60% [Oscasonay = 25% | teTine 0% [oom My student... misses verbal directions in class more than same-aged students. tunes me out or seems to ignore me. tells others to be quiet, becomes distressed during assemblies, lunch, or other large gatherings. 1 2 3 struggles to completo tasks in a noisy setting. 4 5 greets strongly to unexpected or loud noses (or example, re ala, Books dropping to floor, deers slamming, announcements, bells). 7 has difficulty participating in group activities where there is a lot of talking. ‘AUDITORY Raw Score AUDITORY Processing Comments: PSU eee) My student... misses written or demonstrated directions more than same-aged students, struggles to keep materials and supplies organized for use during the day. leaves items blank on a busy worksheet, despite knowing the answers. watches people as they move around the room. locks away from tasks to notice all actions in the room. misses eye cortact with me during everyday interactions, {s attracted to TV or computer screens with fast-paced, brightly colored graphics. VISUAL Raw Score VISUAL Processing Comments: 2 El scHool COMPANION Sensory Profle 2Tate Tone 0 [Oicnnaiy= [Amon ner 10% hms] notea) My student... {9618 100 clase to others when taking face-to-face. 15 18 doesnt seem to notice when face and hands remain diy. 17 touches people or objects to the point of annoying othors. displays need to touch ob} ae 18 jects, surtaces, oF tox example t0-get the feeing ot everything). ee i 19° wants to wipe hands quickly during messy tasks. 29 casily upset by minor inures (or example, bumps into something, scrapes or cuts sel). 21 ses only fingertips to work on projects requring manipulation, 22 _ finches or recoils when body is touched or when others get 100 ose. TOUGH Raw Score TOUCH Processing Comments: eae) My student... falls to steady objects when working (for example, does not hold paper down when waiting). 24 plays or fiddles with objects (for example, pencils, notebooks, folders). is fidgety or cisuptive when stancing inline or close to other people (or ‘example, getting on the bus, entering school, sitting in an assembly). slouches, slumps, or sprawls in chat. ‘bumps into things, faling to notice objects or people in the way. 23 is “on the go.” seems to find endless reasons to approach a teacher. is slower to participate in physically active tasks or activities than same-aged students. MOVEMENT Raw Score 81 stands or sits at the side of the playground during recess" | 32 refuses to participate in team games (for example, soccer, basketball.* tam isnot part of the MOVEMENT law Score. VEMENT Processing Comments: ‘SCHOOL COMPANION Sensory Profie 2 ELic Aasameniled 4 fen My student. does things in a ‘moves slowy). ‘appears tired (for example, has ‘could be described as overreactive students, lacks a sonse of humor. could be described as inflexible compared to same-aged wastes time, harder way than is needed (for example, no energy, is sluggish) ‘or dramatic compared to same~agad students. routines, or expectations. 98 is distressed by changes in plans, 39 can be stubborn or uncooperative, porseverates to point that interferes with participation (for example, can't “shift gears"), 41. _withoraws when there are changes in the environment or routine. 42. gots frustrated easily 43. interacts or participates in groups less than same-aged students. BEHAVIORAL Raw Score eee is bothered by rules being broken.” ‘Ths em fot prt of tho BEHAVIORAL Raw Score BEHAVIORAL Responses Comments:Instructions Tranafor each aw Score Total box ‘Score Total box. Pot Others, lust Like the Majority of Others). the Normal Curve and Sensory Profile 2 Classification System ‘scores one standard devition or more from the meen fe apresced as More Than Others or Less Than Ghhore, rexpectivaly, Seores two standard deviations crises trom the mean ar expressed! as Much More Than Gthore or Much Lees Than Others, respectively. School Factor 1 185 0 / School Factor2 ——/50 O28 ‘School Factor 3 160 oer "For percntle ranges se Aopen Ain the Senscry Profle 2 User's Manual. ‘No scores are ava for Ps ange ‘The degree to which a child obtains sensory input. Acchild | with a Much More Than Others score in this pattern seeks sensory Input ata higher rate than others. “Tho degen to which acids bothered by sensory input. ‘Ach witha Wah Mere Than Ober sere nts pte ‘owes evay om sensory input at a higher rae than others. ‘The degree to which a child detects sensory input wh a Much MoreThan Olen eco nts ela notices sensory input at a higher rate than others, | ence Y mascccn ren mip ha ae | _--55) This factor reflects the student's | external supports to partipate i sCHOOL COMPANION Sensory Profle 2FOR OFFICE USE ONLY EaaSCHOOL 1) @ Companion Sensory PROFILED SCORE SUMMARY and School Factor Grids Instructions Jeor's Mand Please read carefully the detailed ‘hand-scoring instructions in chapter 4 of the Sensory Profile 2 el al. Ganstar the tem raw scores from tho Teacher Questionnalre. Ada ach columa of raw scores to Get ‘Quadrant and School Factor Raw Score Totes __ Quadrant Raw Score Total