| Child’s name: | DOB: |
| Name of screener: | Date of screen: |
How to use the screen:
Sit somewhere quiet and free of distractions. Put the objects out in front of you and see if the child can find the items you ask for. Speak clearly and try not to point or gesture to help the child. If the child gets all three items incorrect then stop there. If they get one or two items correct in a set then keep going.
You will need the following items (or similar items if you are going to substitute): Key, cup, box, plate, duck, pencil, book, big ball, little ball, big spoon, little spoon.
One key word: tick the box if the child points to the item
| key | plate | book | |||
| cup | duck | ball | |||
| box | pencil | spoon |
Actions: give the child a teddy or animal and ask them to do some actions
| jump | sit | sleep | |||
| eat | fly | run |
Two key words: tick the box if the child carries out the action
| Put the key in the cup | |
| Put the ball on the plate | |
| Find the little spoon |
Three key words: tick the box if the child carries out the action
| Put the spoon and key on plate | |
| Give me the duck, pencil and key | |
| Put the big ball in the box |
Four key words: tick the box if the child carries out the action.
| Put the duck and spoon under the box | |
| Put the key in the box, and the pencil in the cup | |
| Put the big spoon under the plate |
