Student Questionnaire

Executive Function Skills

Write your name.

Number your sheet 1 to 3.

Your name

1

2

3

For each statement, decide how often this behavior describes you.

Write the number on your sheet.

1. Even if I’m full, I just can’t stop eating and nibbling.
2. I blurt stuff out in class.
3. I start work before I’ve heard all of the instructions. I rush off.

Mala

1. 2
2. 3
3. 4

Add your numbers together.

This is your score for Response Inhibition.

​

Fill in your bar graph for RI.

Mrs. Magers

• 3
• 4
• 4

11

Write your name.

Number your sheet 1 to 3.

Your name

1

2

3

For each statement, decide how often this behavior describes you.

Write the number on your sheet.

• I forget what I was saying halfway through.
• If I get too many instructions, I can’t remember them all.
• It’s hard to hold a few things in my head at once. (Like chess moves.)

Mala

• 2
• 3
• 4

Add your numbers together.

This is your score for Working Memory.

​

Fill in your bar graph for WM.

Mrs. Magers

• 3
• 2
• 3

8

Write your name.

Number your sheet 1 to 3.

Your name

1

2

3

For each statement, decide how often this behavior describes you.

Write the number on your sheet.

• I feel upset when a teacher tells me I’ve done something wrong or to change my work.
• If something frustrating happens I take a long time to calm down.
• I get worried about things being perfect. I don’t like starting on a project if I’m not sure I can get it perfect.

Mala

• 2
• 3
• 4

Add your numbers together.

This is your score for Emotional Control.

​

Fill in your bar graph for EC.

Mrs. Magers

• 4
• 4
• 4

12

Write your name.

Number your sheet 1 to 3.

Your name

1

2

3

For each statement, decide how often this behavior describes you.

Write the number on your sheet.

• I really dislike it when things change unexpectedly - like a cancelled gym class.
• I find it hard to work in groups. I’d rather stick to my own thinking and ideas.
• I don’t like thinking of different ways to solve problems. I like to know the one BEST way

Mala

• 2
• 3
• 4

Add your numbers together.

This is your score for Flexibility.

​

Fill in your bar graph for F.

Mrs. Magers

• 3
• 4
• 5

12

Write your name.

Number your sheet 1 to 3.

Your name

1

2

3

For each statement, decide how often this behavior describes you.

Write the number on your sheet.

• My mind wanders when I’m reading. I’ll suddenly realize I haven’t been paying attention.
• When listening to people talk I sometimes lose focus and say, “Wait… what?”
• I don’t pay very good attention to proofreading when I’m writing. I don’t notice the little details like punctuation and spelling.

Mala

• 2
• 3
• 4

Add your numbers together.

This is your score for Sustained Attention.

​

Fill in your bar graph for SA.

Mrs. Magers

• 4
• 4
• 4

12

Write your name.

Number your sheet 1 to 3.

Your name

1

2

3

For each statement, decide how often this behavior describes you.

Write the number on your sheet.

• I find it hard to start my homework. I procrastinate.
• Waking up in the morning is really hard. It’s hard to get going.
• I like making big plans but don’t like starting on them.

Mala

• 2
• 3
• 4

Add your numbers together.

This is your score for Task Initiation.

​

Fill in your bar graph for TI.

Mrs. Magers

• 3
• 2
• 3

8

Write your name.

Number your sheet 1 to 3.

Your name

1

2

3

For each statement, decide how often this behavior describes you.

Write the number on your sheet.

• I don’t really plan my weekends and sometimes they are boring.
• I don’t always plan to bring the things I want to have at recess (like a soccer ball or skipping rope), or to get homework done. I’m sometimes not prepared.
• I don’t do a very good job of packing for trips.

Mala

• 2
• 3
• 4

Add your numbers together.

This is your score for Planning/ Prioritizing.

​

Fill in your bar graph for PP.

Mrs. Magers

• 4
• 5
• 5

14

Write your name.

Number your sheet 1 to 3.

Your name

1

2

3

For each statement, decide how often this behavior describes you.

Write the number on your sheet.

• I have a hard time making diagrams or charts look tidy, even, clear, and organized.
• My room, cubby, desk, and schoolbag are pretty messy.
• I sometimes lose things like my water bottle, hat, lunchbox, or sweatshirt.

Mala

• 2
• 3
• 4

Add your numbers together.

This is your score for Organization.

​

Fill in your bar graph for O.

Mrs. Magers

• 4
• 5
• 3

12

Write your name.

Number your sheet 1 to 3.

Your name

1

2

3

For each statement, decide how often this behavior describes you.

Write the number on your sheet.

• I don’t know my schedule at school or for other things like after school lessons or clubs.
• During school, I am sometimes very surprised to find out that time is up for working on a task.
• I can rarely guess what time it is correctly.

Mala

• 2
• 3
• 4

Add your numbers together.

This is your score for Time Management.

​

Fill in your bar graph for TM.

Mrs. Magers

• 3
• 2
• 4

9

Write your name.

Number your sheet 1 to 3.

Your name

1

2

3

For each statement, decide how often this behavior describes you.

Write the number on your sheet.

• I like to help, but I don’t like finishing jobs all the way.
• If I start something tricky and I can’t get it right away I usually give up.
• I start books that should be good for my reading level, but don’t finish them.

Mala

• 2
• 3
• 4

Add your numbers together.

This is your score for Goal Directed Persistence.

​

Fill in your bar graph for GDP.

Mrs. Magers

• 4
• 4
• 5

13

Write your name.

Number your sheet 1 to 3.

Your name

1

2

3

For each statement, decide how often this behavior describes you.

Write the number on your sheet.

• I find myself making the same mistakes again and again.
• I don’t talk about or think about lessons when they’re done.
• I don’t monitor or evaluate as I work, or think about how I’m doing.

Mala

• 2
• 3
• 4

Add your numbers together.

This is your score for Metacognition.

​

Fill in your bar graph for M.

Mrs. Magers

• 4
• 5
• 5

14