Brain Injury Observation Form

Less positive More Positive

ATTENTION SUBTYPE
ATTENTION SUBTYPE	1 Significantly Below Average	2 Slightly Below Average	3 Average	4 Slightly Above Average	5 Significantly Above Average
SELECTIVE/FOCUSED
Focuses on teacher lecture
Attends to detail
Orients to speaker/staff
Looks at board appropriately
Responds to questions with on-topic answers
Resists subtle classroom distractions-noise, lights
SUSTAINED
Focuses for long periods of time
Completes in-class assignments
Looses train of thought when talking or writing
Looses place when working on task or when reading
SHIFTING/DIVIDED
Can multitask-note taking while listening
Can attend to more than one task at a time appropriately
Switches from activity to activity appropriately
Responds when watching audio or video activities
OTHER
Overall attention capacity
Energy level when performing long academic tasks/tests
Organized with materials
Organized thoughts- (analyze writing samples)
Initiates tasks without prompts
Time management (e.g. keeps schedules/dates)
Impulsivity
Talking/ Verbal interruptions

Less positive More Positive

MEMORY
MEMORY	1 Significantly Below Average	2 Slightly Below Average	3 Average	4 Slightly Above Average	5 Significantly Above Average
SHORT TERM MEMORY (When student appears to be paying attention rank the following)
Can repeat back simple information just presented
Can copy from board without frequently looking up
Asks for statements to be repeated
Can complete simple 2-step problems
Follows directions correctly
Can repeat/explain simple activities previously learned on same day
WORKING MEMORY
Completes thought process in writing assignments
Summarizes story/text (names characters, setting, details)
Multi-tasks with accuracy
Completes multistep problems- especially in math/science
Copy from board/note-taking while being taught
LONG TERM MEMORY
Explains previously learned material/facts
Recalls school events from previous week
Remembers where classroom materials are stored
Remembers routines
Remembers vocabulary words
Draws/recognizes previously learned pictures or diagrams
OTHER
Auditory: short term-repeats back 4 words in order (>8 years old)
Working Memory: repeats back 3 given numbers in reverse order (>7 years old)
Visual: student can name pictures / objects that are exposed for a 5-6 seconds

Less positive More Positive

PROCESSING SPEED
PROCESSING SPEED	1 Significantly Below Average	2 Slightly Below Average	3 Average	4 Slightly Above Average	5 Significantly Above Average
Responds to verbal directions/questions quickly
Keeps pace with class
Slow reading (control for comprehension)
Completes tests/tasks on time
Quickly finishes timed tasks accurately
Recalls simple information quickly
Writing or drawing speed
Speech rate
Physical movement
Sometimes seems confused after simple information is provided-not due to attention or memory
Other:

COGNITIVE FATIGUE **Note change of ranking criteria**
COGNITIVE FATIGUE	Observed Frequently	Observed sometimes	Average Compared To Peers	Not Observed Often	Never Observed
Completes morning / earlier academic tasks easier than later tasks
Simple word retrieval consistent throughout day
Attention capacity consistent throughout day
Behavioral changes after moderately difficult test/task
Cognitive changes after moderately difficulty test/task
Reports of fatigue/physical complaints after long tasks
Blank starring
States feeling in a "fog" or feeling "sluggish"
Sensitive to lights / noise after moderate exposure
Other:

Less positive More Positive

EXECUTIVE FUNCTIONS (EF)
EXECUTIVE FUNCTIONS (EF)	1 Significantly Below Average	2 Slightly Below Average	3 Average	4 Slightly Above Average	5 Significantly Above Average
PLANNING, ORGANIZATION, COMPREHENSION, FLEXIBILITY
Organization of materials
Organization of thoughts in writing/ speech
Shifts appropriately from subject to subject
Is able to keep and utilize planner or schedule
Transitions well to different activities
Writes or draws a basic outline of process (ex. logical paragraph)
Difficulty learning new concepts
Difficulty understanding simple stories or concepts
Can explain plans to meet an assignment, task, deadline, or activity
After a short assigned problem, can explain logic used in problem solving
Focuses for appropriate period of time
When engaged in a problem solving task, uses feedback to help in the process (monitors progress)
Can quickly adjust to changes in routine
Keeps track of place when working on task or when reading
EF RELATED BEHAVIOR
Motivation
Impulsivity
Transitions from school activity to activity appropriately
Common sense/judgment
Perspective taking/empathy
Follows rules
Overall attention
Emotional/behavioral regulation
Creativity/concept formation
On-topic reciprocal dialog
Sudden/inappropriate emotions

Less positive More Positive

Sensory/Tactile/Visual/Motor
Sensory/Tactile/Visual/Motor	1 Significantly Below Average	2 Slightly Below Average	3 Average	4 Slightly Above Average	5 Significantly Above Average
SENSORIMOTOR
Posture
Walking/running difficulties
Fine motor (pencil grip/graphomotor) Picking up small pieces
Gross motor
Balance/muscle tone
Touches each finger separately Mimics simple body movements (hand gestures, knock and taps)
Traces or copies figures
Identifies simple objects placed In hand with eyes closed
If clumsy, awkward, unusual movements mark box
VISUAL-SPATIAL/PERCEPTUAL
Skills puzzles / blocks
Understands right vs. left and Up vs. Down
Ignores one side of paper while writing or drawing/coloring
Grossly distorted drawings that are directly copied
Spatial breaks in drawing
TACTILE/AUDITORY/VISUAL
Light Sensitivity
Noise Sensitivity
Touch Sensitivity
Color Blindness
Hearing (ex. Responds to name)
Sees details/writing on board from back of room
Sensitive to temperature
Complains of numbness or odd Sensations
Other:

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