Reproducible forms for

Executive Skills in Children and Adolescents, 3rd edition

by Peg Dawson and Richard Guare
Guilford Publications, Inc.

Form 2.1 Executive Skills Semistructured Form 5.2 Forms for Developing Behavior
Interview—Parent Version Plans/Incentive Systems
Form 2.2 Executive Skills Semistructured Form 6.1 Morning Routine Checklist
Interview—Teacher Version Form 6.2 End-of-Day Routine Checklists
Form 2.3 Executive Skills Semistructured Form 6.3 Daily Homework Planner
Interview—Student Version
Form 6.4 Attention-Monitoring Checklist
Form 2.4 Executive Skills Test Behavior Form 6.5 Desk Cleaning Checklist
Observation Form
Form 6.6 Writing Template for a Five-Paragraph
Form 2.5 Executive Skills Questionnaire Essay
for Parents/Teachers
Form 6.7 Long-Term Project-Planning Sheet
Form 2.6 Executive Skills Questionnaire
for Students Form 6.8 Tools for Studying
Form 2.7 Executive Skills Problem Checklist— Form 6.9 Organizing Notebooks/Homework
Elementary Version for Parents Form 6.10 Note-Taking Template: Cornell Method
Form 2.8 Executive Skills Problem Checklist— Form 6.11 Hard Times Board
Elementary Version for Teachers Form 6.12 Maintaining Self-Control
Form 2.9 Executive Skills Problem Checklist— Form 6.13 Worry Board
Middle/High School Version Form 6.14 Managing Changes in Plans or
Form 2.10 Getting to Know You Schedules
Form 3.1 Intervention Planning Form Form 6.15 Learning Not to Cry over Little Things
Form 3.2 Student-Centered Intervention Form 6.16 Solving Problems Worksheet
Planning Form 10.1 Class Roster for Teams and Coaches
Form 3.3 Child-Centered Interventions Form 10.2 Score Sheet for Math Facts Goal
Instructions for Parents
Form 10.3 Score Sheet for Independent Work
Form 4.1 Progress Monitoring: Response Time
to Intervention
Form 10.4 Score Sheet for Morning Meeting
Form 5.1 Executive Skills Self-Management Behaviors
Checklist
Form 10.5 Score Sheet for End-of-Day Routine

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 FORM 2.1

Executive Skills Semistructured Interview—Parent Version

Many youngsters have problems in school or with homework not because they lack intelligence but
because they have weak executive skills. These refer to the skills required to plan/prioritize (P) and
carry out tasks, including time management (TM), working memory (WM), the ability to organize
tasks and materials (O), task initiation (TI) and follow-through, flexibility (F), response inhibition (RI),
emotional control (EC), sustained attention (SA), goal-directed persistence (GDP), and metacognition
(M). I’m going to ask you some questions about (fill in the child’s name) to
help us get a clearer understanding of his or her executive skills. Codes in parentheses refer to the
specific executive skill measured by each item.

HOMEWORK. Which of the following areas, if any, does your child have difficulty with?

Not a
Item Problem Notes
Understanding homework directions
(M)
Getting started on his or her own (TI)

Being able to keep working despite

distractions (SA)
Asking for help when it’s needed (M)

Sticking with it long enough to

complete it (SA, GDP)
Making careless mistakes; failing to
check work (M)
Finishing the work on time (TM)

Remembering to hand it in (WM)

Are there some subjects or kinds of assignments your child is more likely than others to complete
successfully?

More likely to be successful with . . . Less likely to be successful with . . .

(continued)

From Executive Skills in Children and Adolescents, Third Edition, by Peg Dawson and Richard Guare. Copyright © 2018
The Guilford Press. Permission to photocopy this form is granted to purchasers of this book for personal use or use with
students (see copyright page for details).
 Executive Skills Semistructured Interview—Parent Version (page 2 of 4)

ORGANIZATION OF MATERIALS. Which of the following areas, if any, does your child have difficulty
with?

Not a
Item Problem Notes
Keeping notebooks and papers organized (O)

Keeping desk tidy (O)

Keeping belongings neat and in appropriate locations

(e.g., gym clothes, coats, hats, mittens) (O)

Keeping track of books, papers, pencils, etc. (O)

Keeping backpack organized (O)

LONG-TERM PROJECTS. Which of the following areas, if any, does your child have difficulty with?

Not a
Item Problem Notes
Deciding on a topic (P)

Breaking the assignment into smaller parts (P)

Developing a timeline (P)

Following a timeline (TM)

Estimating how long it will take to finish (TM)

Following directions carefully (WM, M)

Proofreading or checking project to catch mistakes

to make sure the rules were followed (M)

Finishing the project by the deadline (GDP)

(continued)
 Executive Skills Semistructured Interview—Parent Version (page 3 of 4)

REMEMBERING. Which of the following areas, if any, does your child have difficulty with?

Not a
Item Problem Notes
Writing down assignments (WM

Bringing home appropriate materials (e.g., books,

workbooks, assignment book, worksheets,
notices, permission slips, gym clothes) (WM)
Bringing to school appropriate materials (see
examples above) (WM)

Remembering instructional sequences after

normal instruction (e.g., long division, proper
headings for papers) (WM)

Remembering to perform chores or other

household responsibilities (WM)

Losing things within the home, yard, or

neighborhood (WM)

PROBLEM SOLVING. Which of the following areas, if any, does your child have difficulty with?

Not a
Item Problem Notes
Recognizing that he or she has a problem (e.g.,
doesn’t understand the directions) (M)

Being able to think flexibly about the problem (e.g.,

not get stuck on one approach or solution) (F)

Trying to solve the problem first on his or her own

before going for help (M)

Accessing appropriate resources to help him or her

solve the problem (F)

Evaluating his or her own performance to know

whether the problem was solved successfully (M)

(continued)
 Executive Skills Semistructured Interview—Parent Version (page 4 of 4)

SELF-CONTROL. Some youngsters have difficulty managing their behavior. Which of the following
areas, if any, does your child have difficulty with?

Not a
Item Problem Notes
Becoming easily upset (EC)

Throwing temper tantrums (EC)

Acting impulsively, either verbally or

physically (e.g., provoking siblings) (RI)

Interrupting others (RI)

Difficulty waiting turn (RI)

PARENTAL EXECUTIVE SKILLS. Do you see yourself as having challenges in any of the areas we’ve
talked about? If so, in which areas?

Can you envision other problems with starting or following a plan? How or by whom could these
problems be managed?
 FORM 2.2

Executive Skills Semistructured Interview—Teacher Version

Many youngsters have problems in school or with homework not because they lack intelligence but
because they have weak executive skills. These refer to the skills required to plan/prioritize (P) and
carry out tasks, including time management (TM), working memory (WM), the ability to organize
tasks and materials (O), task initiation (TI) and follow-through, flexibility (F), response inhibition (RI),
emotional control (EC), sustained attention (SA), goal-directed persistence (GDP), and metacognition
(M). I’m going to ask you some questions about (fill in the child’s name) to
help us get a clearer understanding of his or her executive skills. Codes in parentheses refer to the
specific executive skill measured by each item.

INDEPENDENT SEATWORK. Which of the following areas, if any, does the student have difficulty
with?

Not a
Item Problem Notes
Understanding task directions (M)

Getting started on his or her own (TI)

Being able to keep working despite distractions (SA)

Asking for help when it’s needed (M)

Sticking with it long enough to complete it (SA, GDP)

Making careless mistakes; failing to check work (M)

Finishing the work on time (TM)

Remembering to hand it in (WM)

Are there some subjects or kinds of assignments that the student is more likely than others to
complete successfully?

More likely to be successful with . . . Less likely to be successful with . . .

(continued)

From Executive Skills in Children and Adolescents, Third Edition, by Peg Dawson and Richard Guare. Copyright © 2018
The Guilford Press. Permission to photocopy this form is granted to purchasers of this book for personal use or use with
students (see copyright page for details).
 Executive Skills Semistructured Interview—Teacher Version (page 2 of 4)

ORGANIZATION OF MATERIALS. Which of the following areas, if any, does the student have
difficulty with?

Not a
Item Problem Notes
Keeping notebooks and papers organized (O)

Keeping desk tidy (O)

Keeping belongings neat and in appropriate locations

(e.g., gym clothes, coats, hats, mittens) (O)

Keeping track of books, papers, pencils, etc. (O)

Keeping backpack organized (O)

LONG-TERM PROJECTS. Which of the following areas, if any, does the student have difficulty with?

Not a
Item Problem Notes
Deciding on a topic (P)

Breaking the assignment into smaller parts (P)

Developing a timeline (P)

Following a timeline (TM)

Estimating how long it will take to finish (TM)

Following directions carefully (WM, M)

Proofreading or checking project to catch

mistakes to make sure the rules were followed
(M)

Finishing the project by the deadline (GDP)

(continued)
 Executive Skills Semistructured Interview—Teacher Version (page 3 of 4)

REMEMBERING. Which of the following areas, if any, does the student have difficulty with?

Not a
Item Problem Notes
Writing down assignments (WM)

Bringing home appropriate materials (e.g.,

books, workbooks, assignment book,
worksheets, notices, permission slips, gym
clothes) (WM)
Bringing to school appropriate materials (see
examples above) (WM)

Remembering to follow classroom procedures

(WM)

Losing things in the classroom or other places in

the school (e.g., lunchroom, gym, playground)
(WM)

Remembering instructional sequences after

normal instruction (e.g., long division, proper
headings for papers) (WM)

PROBLEM SOLVING. Which of the following areas, if any, does the student have difficulty with?

Not a
Item Problem Notes
Recognizing that he or she has a problem (e.g.,
doesn’t understand the directions) (M)

Being able to think flexibly about the problem (e.g.,

not get stuck on one approach or solution) (F)

Trying to solve the problem first on his or her own

before going for help (M)

Accessing appropriate resources to help him or her

solve the problem (F)

Evaluating his or her own performance to know

whether the problem was solved successfully (M)

(continued)
 Executive Skills Semistructured Interview—Teacher Version (page 4 of 4)

SELF-CONTROL. Some youngsters have difficulty managing their behavior. Which of the following
areas, if any, does the student have difficulty with?

Not a
Item Problem Notes
Becoming easily upset (EC)

Throwing temper tantrums (EC)

Acting impulsively, either verbally or

physically (e.g., provoking siblings) (RI)

Interrupting others (RI)

Difficulty waiting turn (RI)

CURRENT EFFORTS TO ADDRESS THE PROBLEM. Please identify the current strategies or
interventions that are being used to address this student’s problem areas and indicate how successful
they are.

TEACHER EXECUTIVE SKILLS. Do you consider yourself as having challenges in any of the areas
we’ve talked about? If so, will this have an impact on your ability to put in place interventions to
address the student’s problem areas?
 FORM 2.3

Executive Skills Semistructured Interview—Student Version

I’m going to ask you some questions about situations related to your success as a student. All of these
are situations in which you have to use planning and organizational skills in order to be successful.
Some will be directly related to school, whereas other questions will touch on extracurricular activities,
any job situations you’ve been in, and how you spend your leisure time.

HOMEWORK. I’m going to ask you some questions about homework and the kinds of problems kids
sometimes have with homework. Please tell me if you think these are problems for you. I may ask you
to give me examples of how you see it as a problem.

Not a
Item Problem Notes
Getting started on homework. (TI)
Related questions: What makes it hard? When is
the best time to do homework? Are some subjects
harder to start than others?

Sticking with it long enough to get it done. (SA)

Related questions: Is this worse with some subjects
than others? What do you say to yourself that either
leads you to give up or stick with it? Does the
length of the assignment make a difference in your
ability to complete it?
Remembering assignments. (WM)
Related questions: Do you have trouble
remembering to write down assignments, bring
home necessary materials, or hand in assignments?
Do you lose things necessary to complete the task?

Becoming distracted while doing homework. (SA)

Related questions: What kinds of things distract
you? Have you found places to study that minimize
distractions? How do you handle the distractions
when they come up?

Having other things you’d rather do. (P, GDP)

Related questions: Are there things you have
trouble tearing yourself away from to do homework?
Do you resent having homework or too much
homework? Do you think there are other things in
your life that are more important than homework?
(continued)

From Executive Skills in Children and Adolescents, Third Edition, by Peg Dawson and Richard Guare. Copyright © 2018
The Guilford Press. Permission to photocopy this form is granted to purchasers of this book for personal use or use with
students (see copyright page for details).
 Executive Skills Semistructured Interview—Student Version (page 2 of 6)

LONG-TERM PROJECTS. Now let’s talk about long-term assignments. Which of the following, if any,
are hard for you?

Not a
Item Problem Notes
Choosing a topic (M)

Breaking the assignment into smaller parts

(P)

Developing a timeline (P)

Sticking with a timeline (TM)

Estimating how long it will take to finish

(TM)

Following directions (e.g., Do you forget to do

part of the assignment and lose points as a
result?) (WM, M)
Proofreading or checking your work to make
sure you followed the rules and haven’t made
careless mistakes (M)
Finishing the project by the deadline (GDP)

STUDYING FOR TESTS. Here are some problems students sometimes have when studying for tests.
Which ones, if any, are a problem for you?

Not a
Item Problem Notes
Making yourself sit down and study (TI)

Knowing what to study (M)

Knowing how to study (M)

Putting off studying/not studying at all (TM)

(continued)
 Executive Skills Semistructured Interview—Student Version (page 3 of 6)

STUDYING FOR TESTS. (continued)

Not a
Item Problem Notes
Taking breaks that are either too frequent or
too long (SA)
Giving up before you’ve studied enough
(GDP)
Memorizing the material (WM)

Understanding the material (M)

HOME CHORES/RESPONSIBILITIES. What kinds of chores, if any, do you have to do on a regular or

irregular basis?

Regular (When do
Chore you do it?) Occasional
1.

2.

3.

4.

5.

What aspects of completing chores, if any, do you have trouble with?

Not a
Item Problem Notes
Remembering to do them (WM)

Doing them when you’re supposed to (TI)

Running out of steam before you’re done (SA)

Doing a sloppy job and getting in trouble for it (M)

(continued)
 Executive Skills Semistructured Interview—Student Version (page 4 of 6)
ORGANIZATIONAL SKILLS. Now I’m going to ask some questions about how organized you are. Tell
me if you have problems with any of the following.

Not a
Item Problem Notes
Keeping your bedroom neat (O)

Keeping your notebooks organized (O)

Keeping your backpack organized (O)

Keeping your desk clean (O)

Keeping your locker clean (O)

Leaving your belongings all over the house (O)

Leaving belongings other places (e.g., school,

friend’s houses, at work) (O)

Losing or misplacing things (O)

WORK/LEISURE TIME. Let’s talk about how you spend your time when you’re not in school. What
kinds of extracurricular activities, if any, are you involved in? Do you have a job? How do you spend
your leisure time?

Amount of time
Activity (approximate per day or week)
1.

2.

3.

4.

5.

6.

7.

(continued)
 Executive Skills Semistructured Interview—Student Version (page 5 of 6)

Here are some problems that students sometimes have with how they spend their spare time. Which
ones, if any, are problems for you?

Not a
Item Problem Notes
Spending too many hours at a job (TM)

“Wasting” time (e.g., hanging out, playing computer/

video games, talking on the phone, time on
Facebook, watching too much TV) (TM)
Hanging out with kids who get in trouble (RI)

Not getting enough sleep (RI)

Spending money as soon as you get it (RI)

LONG-TERM GOALS. Do you know what you want to do after high school?

Possible goals
1.

2.

3.

4.

Have you formulated a plan for reaching your goal(s)? If so, what is it?

(continued)
 Executive Skills Semistructured Interview—Student Version (page 6 of 6)

What are some of the potential obstacles that might prevent you from reaching your goal(s)?

Potential obstacle Ways to overcome the obstacle

1.

2.

3.

4.

5.

If you have not yet identified a goal or developed a plan for reaching the goal, when do you think you
will you do this?
 FORM 2.4

Executive Skills Test Behavior Observation Form

Response Inhibition
Answers questions without thinking
Gives up quickly on challenging tasks
Gives a quick answer and then changes it
Answers question before it has been asked
Tries to begin task without listening to all the instructions
Reaches for materials before the instructions are completed
Uses a trial-and-error approach to more challenging tasks—switches strategies quickly
OTHER:
OTHER:

Working Memory
Asks to have questions or instructions repeated
Remembers the last piece of information but loses information that came early in a sequence
(or remembers what came early and loses the information at the end)
Pauses while working and needs to be prompted to get back to work
Needs reminders of directions
Forgets parts of instructions as the task goes along
OTHER:
OTHER:

Emotional Control
Becomes visibly upset or easily frustrated when tasks or items become challenging
Displays a range of emotions during testing (silliness, anxiety, discouragement, etc.)
Won’t admit he or she doesn’t know the answer to a question (waits for examiner to prompt
or go on to next question)
May make negative statements while working (e.g., “This is tricky”; “I don’t think I can
do this”)
OTHER:
OTHER:
(continued)

From Executive Skills in Children and Adolescents, Third Edition, by Peg Dawson and Richard Guare. Copyright © 2018
The Guilford Press. Permission to photocopy this form is granted to purchasers of this book for personal use or use with
students (see copyright page for details).
 Executive Skills Test Behavior Observation Form (page 2 of 3)

Sustained Attention
Rushes through or gives up quickly on tedious tasks
Stops working when an obstacle is encountered
Asks frequently when the testing or the session will be over
Is drawn off tasks by little distractions
Talks irrelevantly in the middle of working on a subtest
Needs to be reminded to get back to work
OTHER:
OTHER:

Task Initiation
Spends time looking at materials in testing room and needs to be reminded that it’s time
to start working
Is slow to respond to instructions to get started on tasks
OTHER:
OTHER:

Flexibility
Is unable to generate multiple answers to questions
Adjusts slowly to tasks when the instructions change
Can’t figure out a new approach to completing a task when the first approach doesn’t work
Has difficulty analyzing a multistep problem
Uses a trial-and-error approach to problem solving
Performance improves as the task progresses (seems slow to learn the task)
OTHER:
OTHER:

Metacognition
Shows no evidence of “thinking through” problems—either knows an answer or doesn’t
May not realize he or she doesn’t understand directions for tasks
Is not aware that more than one strategy may be necessary
Doesn’t check work
Can’t improve answers with further prompts
OTHER:
OTHER:
(continued)
 Executive Skills Test Behavior Observation Form (page 3 of 3)

Time Management
Does not adjust pace of work when he or she knows he or she is being timed or that time
is running out
OTHER:
OTHER:

Planning and Organization

Has no systematic strategy for solving a problem or completing a task
Shifts randomly between strategies when an obstacle is encountered
OTHER:
OTHER:

Goal-Directed Persistence
Stops working on tasks when they become difficult or effortful
Doesn’t show determination when confronted with challenging tasks (e.g., doesn’t say things
like “I’m going to get this one!” or “You can’t trick me”)
If given the option of finishing now or finishing later, chooses later
OTHER:
OTHER:
 FORM 2.5

Executive Skills Questionnaire for Parents/Teachers

Big problem 1
Moderate problem 2
Mild problem 3
Slight problem 4
No problem 5
Item Score
1. Acts on impulse
2. Gets in trouble for talking too much in class
3. Says things without thinking
TOTAL SCORE:

4. Says, “I’ll do it later” and then forgets about it

5. Forgets homework assignments or forgets to bring home
needed materials
6. Loses or misplaces belongings such as coats, mittens, sports
equipment, etc.
TOTAL SCORE:
7. Gets annoyed when homework is too hard or confusing or takes
too long to finish
8. Has a short fuse; easily frustrated
9. Easily upset when things don’t go as planned
TOTAL SCORE:

10. Difficulty paying attention; easily distracted

11. Runs out of steam before finishing homework or other tasks
12. Problems sticking with schoolwork or chores until they are done
TOTAL SCORE:

13. Puts off homework or chores until the last minute

14. Difficulty setting aside fun activities in order to start homework
15. Needs many reminders to start chores
TOTAL SCORE:

16. Trouble planning for big assignments (knowing what to do first,

second, etc.?
17. Difficulty setting priorities when has a lot of things to do
18. Becomes overwhelmed by long-term projects or big assignments
TOTAL SCORE:
(continued)

From Executive Skills in Children and Adolescents, Third Edition, by Peg Dawson and Richard Guare. Copyright © 2018
The Guilford Press. Permission to photocopy this form is granted to purchasers of this book for personal use or use with
students (see copyright page for details).
 Executive Skills Questionnaire for Parents/Teachers (page 2 of 2)

Item Score
19. Backpack and notebooks are disorganized
20. Desk or workspace at home or school is a mess
21. Trouble keeping bedroom or locker tidy
TOTAL SCORE:

22. Has a hard time estimating how long it takes to do something

(such as homework?
23. Often doesn’t finish homework at night; rushes to get it done in school
before class
24. Slow getting ready for things (e.g., appointments, school,
changing classes?
TOTAL SCORE:

25. If the first solution to a problem doesn’t work, has trouble thinking
of a different one
26. Resists changes in plans or routines
27. Has problems with open-ended homework assignments (e.g., doesn’t
know what to write about when given a creative writing assignment?
TOTAL SCORE:

High School Students Only

28. Lacks effective study strategies
29. Doesn’t check work for mistakes even when the stakes are high
30. Doesn’t evaluate performance and change tactics in order to
increase success
TOTAL SCORE:

31. Can’t seem to save up money for a desired object; problems

delaying gratification
32. Doesn’t see the value in earning good grades to achieve
a long-term goal
33. Seems to live in the present
TOTAL SCORE:
KEY
Items Executive Skill Items Executive Skill
1–3 Response inhibition 4–6 Working memory
7–9 Emotional control 10–12 Sustained attention
13–15 Task initiation 16–18 Planning/prioritization
19–21 Organization 22–24 Time management
25–27 Flexibility 28–30 Metacognition
31–33 Goal-directed persistence

Child’s Executive Skills Strengths Child’s Executive Skills Weaknesses

 FORM 2.6

Executive Skills Questionnaire for Students

Directions: Read each item and decide how often it’s a problem for you. Then add up the three scores
in each set and write that number on the Total score line. Use the Key on page 271 to determine your
executive skills strengths (two to three highest scores) and weaknesses (two to three lowest scores).

1. I act on impulse.
Most of the time Frequently Sometimes Very rarely Never
1 2 3 4 5

2. I get in trouble for talking too much in class.

Most of the time Frequently Sometimes Very rarely Never
1 2 3 4 5

3. I say things without thinking.

Most of the time Frequently Sometimes Very rarely Never
1 2 3 4 5
Total score, items 1–3:

4. I say “I’ll do it later” and then forget about it.

Most of the time Frequently Sometimes Very rarely Never
1 2 3 4 5

5. I forget homework assignments or forget to bring home needed materials.

Most of the time Frequently Sometimes Very rarely Never
1 2 3 4 5

6. I lose or misplace belongings such as coats, notebooks, sports equipment, etc.

Most of the time Frequently Sometimes Very rarely Never
1 2 3 4 5
Total score, items 4–6:

7. I get annoyed when homework is too hard or confusing or takes too long to finish.
Most of the time Frequently Sometimes Very rarely Never
1 2 3 4 5

8. I have a short fuse, am easily frustrated.

Most of the time Frequently Sometimes Very rarely Never
1 2 3 4 5

9. I get upset easily when things don’t go as planned.

Most of the time Frequently Sometimes Very rarely Never
1 2 3 4 5
Total score, items 7–9:

(continued)

Reprinted from Dawson and Guare (2017). Copyright © 2017 The Guilford Press.

From Executive Skills in Children and Adolescents, Third Edition, by Peg Dawson and Richard Guare. Copyright © 2018
The Guilford Press. Permission to photocopy this form is granted to purchasers of this book for personal use or use with
students (see copyright page for details).
 Executive Skills Questionnaire for Students (page 2 of 4)

10. I have difficulty paying attention, am easily distracted.

Most of the time Frequently Sometimes Very rarely Never
1 2 3 4 5

11. I run out of steam before finishing my homework.

Most of the time Frequently Sometimes Very rarely Never
1 2 3 4 5

12. I have problems sticking with chores until they are done.
Most of the time Frequently Sometimes Very rarely Never
1 2 3 4 5
Total score, items 10–12:

13. I put off homework or chores until the last minute.

Most of the time Frequently Sometimes Very rarely Never
1 2 3 4 5

14. It’s hard for me to put aside fun activities to start homework.
Most of the time Frequently Sometimes Very rarely Never
1 2 3 4 5

15. I need many reminders to start chores.

Most of the time Frequently Sometimes Very rarely Never
1 2 3 4 5
Total score, items 13–15:

16. I have trouble planning for big assignments (knowing what to do first,
second, etc.).
Most of the time Frequently Sometimes Very rarely Never
1 2 3 4 5

17. It’s hard for me to set priorities when I have a lot of things to do.
Most of the time Frequently Sometimes Very rarely Never
1 2 3 4 5

18. I become overwhelmed by long-term projects or big assignments.

Most of the time Frequently Sometimes Very rarely Never
1 2 3 4 5
Total score, items 16–18:

(continued)
 Executive Skills Questionnaire for Students (page 3 of 4)

19. My backpack and notebooks are disorganized.

Most of the time Frequently Sometimes Very rarely Never
1 2 3 4 5

20. My desk or workspace at home is a mess.

Most of the time Frequently Sometimes Very rarely Never
1 2 3 4 5

21. I have trouble keeping my room tidy.

Most of the time Frequently Sometimes Very rarely Never
1 2 3 4 5
Total score, items 19–21:

22. I have a hard time estimating how long it takes to do something

(such as homework).
Most of the time Frequently Sometimes Very rarely Never
1 2 3 4 5

23. I often don’t finish homework at night and rush to get it done in school
before class.
Most of the time Frequently Sometimes Very rarely Never
1 2 3 4 5

24. I’m slow getting ready for things (for example, school or appointments).
Most of the time Frequently Sometimes Very rarely Never
1 2 3 4 5
Total score, items 22–24:

25. If the first solution to a problem doesn’t work, I have trouble thinking
of a different one.
Most of the time Frequently Sometimes Very rarely Never
1 2 3 4 5

26. It’s hard for me to deal with changes in plans or routines.

Most of the time Frequently Sometimes Very rarely Never
1 2 3 4 5

27. I have problems with open-ended homework assignments (e.g., knowing

what to write about for a creative writing assignment or coming up with topics
for a long-term project).
Most of the time Frequently Sometimes Very rarely Never
1 2 3 4 5
Total score, items 25–27:

(continued)
 Executive Skills Questionnaire for Students (page 4 of 4)

28. I don’t have effective study strategies.

Most of the time Frequently Sometimes Very rarely Never
1 2 3 4 5

29. I don’t check my work for mistakes even when the stakes are high.
Most of the time Frequently Sometimes Very rarely Never
1 2 3 4 5

30. I don’t evaluate my performance and change tactics to increase my success.

Most of the time Frequently Sometimes Very rarely Never
1 2 3 4 5
Total score, items 28–30:

31. I can’t seem to save up money for something I want.

Most of the time Frequently Sometimes Very rarely Never
1 2 3 4 5

32. I don’t see the value in earning good grades to achieve a long-term goal.
Most of the time Frequently Sometimes Very rarely Never
1 2 3 4 5

33. If something fun comes up when I should be studying, it’s hard for me
to make myself study.
Most of the time Frequently Sometimes Very rarely Never
1 2 3 4 5
Total score, items 31–33:

KEY
Items Executive Skill Items Executive Skill
1–3 Response inhibition 4–6 Working memory
7–9 Emotional control 10–12 Sustained attention
13–15 Task initiation 16–18 Planning/prioritization
19–21 Organization 22–24 Time management
25–27 Flexibility 28–30 Metacognition
31–33 Goal-directed persistence

Your Executive Skills Strengths Your Executive Skills Weaknesses

 FORM 2.7

Executive Skills Problem Checklist—Elementary Version for Parents

Directions:
1. Read each item and decide whether your child exhibits this problem to a significant degree such
that it interferes with daily life at home. Keep in mind that some of the items may not be age
appropriate for your child.
2. Look over all the items you checked and choose THREE that you think cause the greatest
problems. Place a star () next to those.

Response Inhibition
Interrupts when others are talking
Blurts out inappropriate comments
Can’t wait turn in games or conversations
Doesn’t use acceptable language to handle conflict situations
Doesn’t consider consequences before acting
Rushes through homework or chores without regard to quality of work

Working Memory
Can’t remember short instructions even right after they’re given
Does not bring all necessary materials to and from school every day (e.g., homework,
notebooks/binders, permission slips, gym clothes, lunch money, coats/hats/mittens)
Has trouble keeping track of schedule when it changes from day to day
Doesn’t remember things necessary for activities outside the home (e.g., sports equipment)
Doesn’t remember to do chores, even when they follow a consistent schedule

Emotional Control
Becomes easily upset over small things that would not bother others
Engages in verbal or physical aggression when angry
Fails to use coping strategies to recover when he or she begins to get upset (or angry,
frustrated, anxious)
Overreacts when provoked by things people say or do to him or her
Gets “revved up” in some situations (e.g., social gatherings) and has trouble calming down
Has trouble dealing with disappointment, such as losing at a game or not getting what he or
she wants
(continued)

From Executive Skills in Children and Adolescents, Third Edition, by Peg Dawson and Richard Guare. Copyright © 2018
The Guilford Press. Permission to photocopy this form is granted to purchasers of this book for personal use or use with
students (see copyright page for details).
 Executive Skills Problem Checklist—Elementary Version for Parents (page 2 of 3)

Flexibility
Doesn’t use coping strategies to recover when he or she begins to get upset (or angry,
frustrated, anxious)
Has difficulty managing transitions between activities or settings
Can’t do open-ended homework assignments (e.g., using each spelling word in a sentence or
doing a creative writing assignment)
Is unable to come up with one or more alternative plan or solution when the first strategy
doesn’t work (no Plan B)
Gets stuck or fixated on certain thoughts or ideas

Sustained Attention
Doesn’t complete homework or chores within the time allotted or within suggested
time frames
Gets up and down during homework—difficulty sticking with it long enough to get it done
Doesn’t listen when parents or other adults are talking to him or her
Shifts quickly from one play activity to another
Doesn’t stay focused when engaged in organized activities (e.g., sports)

Task Initiation
Doesn’t perform daily routines at scheduled times unless prompted
Leaves homework or chores until the last minute unless prompted by an adult
Finds other things to do rather than chores, homework, and daily routines
Stretches out breaks and fails to return to work promptly with longer work tasks
Dawdles when asked to do a chore, perform a boring daily routine, or the switch from
a preferred to a nonpreferred activity

Planning/Prioritization
Has difficulty setting priorities (in what order to do tasks, how much time to spend on any
given task)
Can’t make a plan to accomplish a task (even when it’s something the he or she wants to do)
Gets sidetracked when following a plan and doesn’t get back to it
Doesn’t know what to focus on when studying for tests
Can’t break down a task into individual steps (what to do first, second, etc.)
(continued)
 Executive Skills Problem Checklist—Elementary Version for Parents (page 3 of 3)

Organization
Doesn’t hang up coats/put belongings away in designated place
Doesn’t place materials in a specified place in notebooks, backpacks, desks, and study areas
Doesn’t follow an organizational system with consistency (e.g., throwing out unnecessary
papers, placing homework assignments in assigned spot, organizing school papers)
Doesn’t have a tidy study area to work at
Bedroom and play spaces are a mess and this doesn’t bother him or her

Time Management
Does not arrive places on time (e.g., coming home from friend’s house at agreed-upon time)
Can’t complete daily routines within time limits
Does not complete assignments by the due date
Can’t adjust work speed to fit the time available
Can’t juggle multiple time demands (e.g., starting homework early on days when child has
evening Scout meetings)

Goal-Directed Persistence
Does not persist with effortful tasks
Gives up in the face of an obstacle
Starts projects but doesn’t finish them (including preferred activities)
Wants to quit rather than do the work to get better at something
Has a “good-enough” mentality that gets in the way of producing quality work
Can’t save up money to make a desired purchase

Metacognition
Can’t judge the quality of his or her own work
Does not know how to improve work
Can’t solve everyday problems
Has difficulty making inferences, drawing conclusions, grasping the main idea, reading
between the lines
Can’t read or misinterprets the emotions or reactions of others
Fails to check work/proofread
 FORM 2.8

Executive Skills Problem Checklist—Elementary Version

for Teachers
Directions:
1. Read each item and decide whether the student in question exhibits this problem to a significantly
greater degree than other children in the same grade level.
2. Look over all the items you checked and choose THREE that you think cause the greatest
problems. Place a star () next to those.

Response Inhibition
Blurts out inappropriate comments
In a teacher-directed activity, does not wait until the person talking finishes and is
acknowledged by the teacher before offering a response
Can’t wait turn in games
Does not use acceptable language to handle conflict situations
Does not remain at his or her seat or assigned area during seatwork time and classroom
lessons
Does not complete seatwork or assignments accurately

Working Memory
Doesn’t write down all homework in assignment books or other designated location
Doesn’t bring all necessary materials to and from school every day (e.g., homework,
notebooks/binders, permission slips, gym clothes, lunch money, coats/hats/mittens)
Doesn’t hand in assignments on the dates they are due
Doesn’t remember where to find all necessary materials to get through the school day and to
complete homework
Doesn’t follow all instructions accurately for multistep tasks by using checklists or rubrics if
necessary

Emotional Control
Leaves class or becomes visibly upset rather than asking for help when he or she doesn’t
understand an assignment
Engages in verbal or physical aggression or unsafe behavior when playing with other students
at recess
Doesn’t use coping strategies to recover when he or she begins to get upset (or angry,
frustrated, anxious)
(continued)

From Executive Skills in Children and Adolescents, Third Edition, by Peg Dawson and Richard Guare. Copyright © 2018
The Guilford Press. Permission to photocopy this form is granted to purchasers of this book for personal use or use with
students (see copyright page for details).
 Executive Skills Problem Checklist—Elementary Version for Teachers (page 2 of 3)

Anxiety interferes with test performance

Anxiety interferes with classroom presentations
Becomes very upset or responds with verbal or physical aggression when teased or taunted by
other students

Flexibility
Becomes very upset when confronted with the unexpected (e.g., changes in plans or routines,
disappointment, being told “no”)
Has difficulty managing transitions between activities or settings
Is unable to come up with one or more alternative plans or solutions when the first strategy
doesn’t work (no Plan B)
Is unable to complete open-ended tasks successfully according to the rubric assigned

Sustained Attention
Doesn’t complete classwork and homework within the time allotted or within suggested time
frames
Loses focus on class lessons (as demonstrated by not being able to answer questions related
to the content of the lesson or by not understanding assignments associated with the lesson)

Task Initiation
Has difficulty starting class assignments within 3 minutes of the prompt to begin working
Stretches out breaks and fails to return to work promptly with longer or less preferred work
tasks

Planning/Prioritization
Has difficulty setting priorities (in what order to do tasks, how much time to spend on any
given task)
Doesn’t know what to focus on when studying for tests
Writing does not follow a logical sequence; paragraphs don’t contain main ideas and
supporting details

Organization
Does not place materials in a specified place in notebooks, backpacks, desks, and study areas
Does not follow an organizational system with consistency (e.g., throwing out unnecessary
papers, placing homework assignments in assigned spot, organizing papers for each subject
separately)
Does not have a tidy study area
(continued)
 Executive Skills Problem Checklist—Elementary Version for Teachers (page 3 of 3)

Time Management
Does not complete assignments within the time allotted or by the due date
Can’t adjust work speed to fit the time available

Goal-Directed Persistence
Does not persist with effortful tasks
Gives up in the face of an obstacle
Has a “good-enough” mentality that gets in the way of producing quality work

Metacognition
Cannot judge the quality of his or her own work
Does not know how to improve work
Has difficulty making inferences, drawing conclusions, grasping the main idea, reading
between the lines
Fails to check work/proofread/use spell-check
 FORM 2.9

Executive Skills Problem Checklist—Middle/High School Version

Directions:
1. Check (9) problem areas that significantly interfere with effective studying.
2. Look over all the items you checked and choose THREE that you think cause the greatest
problems. Place a star () next to those.

Response Inhibition
Rushing through work just to get it done
Not having the patience to produce quality work
Giving up on a homework assignment when I encounter an obstacle
Having trouble doing homework when there are more fun things to do

Working Memory
Writing assignment instructions without enough detail to understand later
Forgetting to take home necessary materials or take materials to class
Forgetting to hand in homework
Forgetting long-term projects or upcoming tests
Not paying attention to classroom instructions/task directions
Trouble remembering multiple directions or multiple problem steps
Losing materials
Forgetting to complete assignments
Forgetting to check agenda/assignment book
Not recording when an assignment is due

Emotional Control
Getting really irritated when a homework assignment is hard or confusing
Finding it hard to get started on assignments because of perfectionism or fear of failure
Freezing when taking tests and doing poorly despite studying long and hard
Not seeing the point of an assignment and finding it hard to motivate myself to do it

(continued)

From Executive Skills in Children and Adolescents, Third Edition, by Peg Dawson and Richard Guare. Copyright © 2018
The Guilford Press. Permission to photocopy this form is granted to purchasers of this book for personal use or use with
students (see copyright page for details).
 Executive Skills Problem Checklist—Middle/High School Version (page 2 of 4)

Task Initiation
Procrastinating/avoiding tasks due to:
not knowing how to get started
believing the task will “take forever”
believing my performance won’t meet expectations
seeing the task as tedious, boring, or irrelevant
Finding other things to do rather than starting homework
Having difficulty getting back to work after breaks

Sustained Attention
Taking frequent breaks when working
Taking breaks that are too long
Internally distracted—thoughts, states, moods, daydreams (please specify):

Externally distracted—sights, sounds, technology such as phone, computer, TV, video games
(please specify):
Rushing through work—sloppy/mistakes
Not knowing limits (e.g., how long I can sustain attention) or when the best study time is
Not recognizing when I’m off task

Planning/Prioritization
Not making a study plan (may not know how)
Can’t break down long-term projects into smaller tasks and timelines
Having difficulty taking notes or studying for test because I can’t distinguish important from
nonimportant
Not using or not knowing how to use agenda/assignment book
Spending too much time on less important elements—can’t put the most important parts or
most important assignments first
Planning unrealistically (e.g., fail to take into account obstacles to the plan)

Flexibility
Struggling with assignments that require creativity or are open-ended
Getting stuck on one solution or one way of looking at a problem
Having trouble coming up with topics or ideas of things to write about
Having difficulty coming up with “Plan B” if the first attempt didn’t work
(continued)
 Executive Skills Problem Checklist—Middle/High School Version (page 3 of 4)

Organization
Not using or knowing how to design an organizational system
Not being able to find things in notebooks or backpacks
Losing assignments or important papers
Not having neat study area
Losing electronic data—forget where work is stored or what name it’s filed under

Time Management
Can’t estimate how long a task will take—due to:
overestimating how long it will take to do a task (therefore never getting started)
underestimating how long it will take to do a task (therefore running out of time)
Chronically late (for school, tutoring, other appointments, and obligations)
Having difficulty juggling multiple assignments and responsibilities because I can’t judge
time involved
Overcommitted—juggling too many obligations (and I think I can pull it off!)
Lacking a sense of time urgency (I don’t appreciate that deadlines are important)
Relying on deadline as activator or motivator

Goal-Directed Persistence
Not having a long-term goal
Having a long-term goal but lacking a realistic plan to achieve the goal
Not seeing how daily actions impact goal attainment
Not seeing studying as important and making minimal effort as a result
Giving up in the face of an obstacle
Having a “good-enough” mentality that gets in the way of producing quality work
“Not on the radar”— seeing work as not relevant or not important enough to do

Metacognition
Can’t accurately evaluate skills (e.g., expect to do well on tests in spite of poor past
performance, expect to go to a college or get a job without requisite skills or academic record)
Can’t identify appropriate study strategies
Can’t plan or organize a writing assignment
Can memorize facts but missing the larger context (I do better on multiple-choice tests than
essay questions)
Having a hard time understanding more abstract concepts (math as well as content-area
subjects)
(continued)
 Executive Skills Problem Checklist—Middle/High School Version (page 4 of 4)

Having difficulty making inferences, drawing conclusions, grasping the main idea, and reading
between the lines
Failing to check work/proofread

Other

WHAT ARE MY TARGETS?

Executive Skill Specific Problem

What are some ways that I could use my executive skills strengths to help me be successful?
 FORM 2.10

Getting to Know You

Name:

1. How do you spend your spare time? Check (v) all that apply and draw a circle around your favorite
three activities.
with family TV/DVDs reading theater/dance part-time job
with friends alone sports Internet, IM video/computer games
outdoors sleeping writing listening to music volunteering
arts, crafts, building things playing an instrument extracurricular activities at school
dirt biking/four-wheeling OTHER:

2. What talents do you have? Check all that apply and provide an example if you can.
Athletic: Artistic:
Musical: Writing:
Communication: Leadership:
Performing arts: Technology:
Mechanical skills: Math/sciences:
Cooking, sewing: Interpersonal skills:
OTHER:

3. What personal qualities do you have that you consider to be strengths? Check up to five.
leadership patience creativity sense of humor independence
caring, empathy hard worker loyalty imagination dependability
determination optimism self-control coping skills problem solving
persistence ambition honesty organization courage
competitiveness extraversion (outgoing) working well with others
OTHER:

4. What areas of skill or knowledge would you like to become an expert in? List any topic that
interests you, even if it is something you don’t usually learn about in school (e.g., skateboarding,
video games, sports statistics, cheerleading, horseback riding).

(continued)

From Executive Skills in Children and Adolescents, Third Edition, by Peg Dawson and Richard Guare. Copyright © 2018
The Guilford Press. Permission to photocopy this form is granted to purchasers of this book for personal use or use with
students (see copyright page for details).
 Getting to Know You (page 2 of 2)

5. How do you learn best? Check all that apply.

a. Group size:
alone small group (2–4 people)
medium group (5–7 people) whole class

b. Learning style:
visual hands on
listening memorizing
discussion activity/experiential learning
apprenticeship taking notes
reading thinking about what I’ve read or heard
OTHER:

c. What is your preferred study environment?

library study hall at school
bedroom other room in my house
with friends public place (e.g., coffee shop)
resource room OTHER:

6. What are your preferred classroom activities? Check all that apply.
lecture discussions projects
debates group games presentations
reading creative writing worksheets
labs/experiments cooperative learning brainstorming
outdoor activities field trips learn, then teach others
role playing simulations taking tests
self-directed learning individual research doing homework
movies/DVDs working on the computer teacher-led instruction
doodling daydreaming talking with friends
OTHER:
 FORM 3.1

Intervention Planning Form

Problem Description: What
does the behavior look like?
What task, situation, or
directive is most likely to elicit
the behavior?

Executive Skill(s): What

skills do you think might be
involved?

Setting: Where, when, or

under what circumstances
does the behavior usually
occur?

Where to Start: If you could

change one small part of
the student’s behavior that
would lead you to say, “This
is better,” what would that
behavior be?

Environmental Modifications: Check all that apply:

How can the situation be Change physical or social environment (e.g., add physical
modified so the student has a barriers, reduce distractions, provide organizational structures,
greater likelihood of success? reduce social complexity)
Change the nature of the task (e.g., make shorter, build in
breaks, give something to look forward to, create a schedule,
build in choice, make the task more fun)
Change the way adults interact with the child (e.g., rehearsal,
prompts, reminders, coaching, praise, debriefing, feedback)

(continued)

From Executive Skills in Children and Adolescents, Third Edition, by Peg Dawson and Richard Guare. Copyright © 2018
The Guilford Press. Permission to photocopy this form is granted to purchasers of this book for personal use or use with
students (see copyright page for details).
 Intervention Planning Form (page 2 of 2)

Possible Motivator: What Check all that apply:

would help the student be
Specific praise
more likely to try? Can you
use a simple reward system? Something to look forward to when the task (or a piece of the
Alternate between preferred task) is done
and nonpreferred activities? A menu of rewards and penalties
Other ideas?
Daily reward possibilities:

Weekly reward possibilities:

Long-term reward possibilities:

Goal Behavior: There are Process goal: This should identify the strategy the student will use
two parts to this: process to achieve the outcome goal:
and outcome. Both should
be phrased as “[Student]
will . . . [do what?].” Outcome goal: This is the end point to the intervention. What do
you want the student to do differently?

Intervention Implementation Who will supervise the intervention?

Steps
What steps will be followed?
1.
2.
3.
4.
5.
6.

Visual Feedback to Show

Progress: What visual
feedback can you give the
student so he or she can
clearly see that progress
is being made? Graph?
Checklist? Behavior counts?
Tracking grades on tests?
Other ideas?
 FORM 3.2

Student-Centered Intervention Planning

Student’s Name:
Teacher’s Name:
Start Date:

Executive Skill:
Recurring situation in which the executive skill weakness affects behavior:

Step Planning Phase Date Completed

1 Gather baseline data—ideally objective (e.g., behavior counts), or create a
vivid picture of the behavior to share with the student.
2 Share the data/observations with the student.
3 If appropriate, have the student observe another student in the class who
handles the situation well; ask what the student observed and list the
observations.

4 Ask for input from the student, and then brainstorm strategies the student
might try to improve the behavior; have the student select a strategy to try;
review process with student so he or she understands how it will work.

What strategy has the student agreed to try?

Start date for implementing the plan:

Step Implementation Phase Dates Plan Followed

5 Just before the target situation, ask the student what the plan is. In
the beginning, keep the practice sessions brief and compliment the
student often.
6 Prompt during the target situation if the student doesn’t remember to
use the strategy independently.
7 Debrief afterward—ask the student how it went before giving
feedback. Find something to praise and be specific.

(continued)

From Executive Skills in Children and Adolescents, Third Edition, by Peg Dawson and Richard Guare. Copyright © 2018
The Guilford Press. Permission to photocopy this form is granted to purchasers of this book for personal use or use with
students (see copyright page for details).
 Student-Centered Intervention Planning (page 2 of 2)

Step Implementation Phase Dates Plan Followed

8 Troubleshoot and revise plan as necessary.
9 Collect postintervention data—ideally 1 week out, 2 weeks, 1 month.

Postintervention Evaluation

What worked well?

What didn’t work so well?

Is there a logical “next step” (e.g., should the student be recycled through the process choosing a
different executive skill or target situation)?
 FORM 3.3

Child-Centered Interventions Instructions for Parents

Whenever possible, we recommend involving the child in identifying specific problem areas to address
and generating possible intervention strategies. Suggested steps to do this are:

1. Collect some data about the nature of the problem (e.g., how long it takes your child to get
through his or her homework without supervision). The problem should be discrete, specific, and
“countable.” We recommend collecting 1–2 weeks of baseline data, both to have some clear
evidence to share with your child and to ensure that it truly is a significant problem.
2. Share the data with your child and suggest that together you come up with a plan of attack for
solving the problem.
3. Together, brainstorm different strategies. If your child has trouble thinking of strategies on his or her
own, then you should make three or four suggestions for things he or she might consider trying.
4. Have your child select a strategy to try.
5. If appropriate, build in daily short practice sessions for trying out the strategy (e.g., try it out with
a portion of his or her homework). Practice sessions need to be short in order to ensure early
success. Daily practice is also important so that your child gets frequent opportunities to practice.
6. Remind your child of the chosen strategy at the appropriate time (e.g., when he or she is making a
homework plan and just before he or she begins the homework).
7. Provide positive feedback to your child for using his or her strategy or following his or her plan.
8. Debrief with your child periodically about how he or she thinks the plan is working. If changes need
to be made, ask your child to suggest reasonable changes and offer some suggestions yourself.

What Might This Look Like?

Problem behavior: leaving homework until just before bedtime and then being too tired to get it done
or rushing through it.

1. Collect baseline data—for example, count the number of homework nights when your child gets
mad about doing his or her homework because he or she is “too tired.”
2. Share the data with your child. You might say to your child on Sunday, “Tracy, last week you
had homework four nights and on all four nights, you put it off until just before bed and then
complained about having to do it. I think that frustrated both of us because you were too tired to
do your best work and just wanted to quit.”
3. Say to your child, “Can we come up with a plan to avoid this?” Ask the child for suggestions. If your
child can’t think of anything, you might say, “I’ve got some ideas. Let me throw them out and see
whether there’s one you’re willing to try. Let’s make a list.” The list might look like this:
• Do your homework as soon as you get home from school.
• Agree to start it at 5 o’clock and finish it before dinner.
• Start it right after dinner.
• Hold off doing a fun activity (like playing video games) until the homework is done, so that you
have something to look forward to doing when the hard work is behind you.
4. Ask your child, “So which of these do you want to choose? Or do you have another idea?”
(continued)

From Executive Skills in Children and Adolescents, Third Edition, by Peg Dawson and Richard Guare. Copyright © 2018
The Guilford Press. Permission to photocopy this form is granted to purchasers of this book for personal use or use with
students (see copyright page for details).
 Child-Centered Interventions Instructions for Parents (page 2 of 2)

5. When your child has made a selection, you can say, “OK, since we’re trying something different,
I’m going to remind you when you get home from school the plan that we’ve agreed on. Does that
make sense?”
6. Cue your child as agreed upon.
7. Praise your child for following the plan (but don’t overdo it): “Hey, thanks for trying out this new
homework plan. I noticed you and I were both less frustrated.”
8. After it’s been in place for a week, debrief with your child: “How do you think this is going? What
do you think is positive? Is there anything that’s negative? Can we fix it in any way to make it
better?”
9. Continue with the plan until it becomes habitual.

Additional suggestions:
• You might create a chart to give your child a visual to remember the plan and to track progress. It
might look like this:

Homework Plan Monday Tuesday Wednesday Thursday

Start work at 5:00 P.M.;
finish by dinner. Put an X
in each box on the days
the plan is followed.

• One of the most effective strategies for encouraging children to do something they’d prefer not to
is to ensure that they have a preferred activity to do as soon as the effortful task is finished (e.g.,
holding off playing video games until homework is done). We call this a first–then plan (first work,
then play). If this by itself is not sufficient, your child could earn points for each day he or she
successfully completes the homework by dinner. Points could be traded in for a small reward or a
preferred activity.
• If it’s too much to expect your child to do all his or her homework at the agreed-upon time, you
could begin by having your child work for 10 minutes or complete a certain amount of his or her
homework (e.g., five math problems) and gradually increase the time/workload until your child is
able to do all the homework by then.
• If your child’s after-school schedule varies from day to day or is unpredictable, the plan might be to
set a start time each day right after school. The chart to track progress might look like this:

Homework Plan Monday Tuesday Wednesday Thursday

Start time:
I stuck to my start time
(X in box).
 FORM 4.1

Progress Monitoring: Response to Intervention

Student’s Name:

Tier Start Review Measurement

level Intervention date date Criterion for success procedure Outcome Next step

From Executive Skills in Children and Adolescents, Third Edition, by Peg Dawson and Richard Guare. Copyright © 2018 The Guilford Press. Permission to photocopy this form is
granted to purchasers of this book for personal use or use with students (see copyright page for details).
 FORM 5.1

Executive Skills Self-Management Checklist

Check if
included in
Element What does student participation look like? intervention
Selection of target Student helps identify what behavior problem needs to be
behavior addressed.

Definition Student involved in developing operational definition of the

target behavior (e.g., “keep hands to self during circle time”).

Selection of primary Student is asked to identify possible reinforcers; helps create

reinforcers a reinforcement menu.

Performance goal Student helps set a reasonable goal for the target behavior
(e.g., “Remember to raise my hand x% of the time”).

Instructional prompt Student helps decide the best way to remember to prompt for
the behavior (e.g., use of kitchen timer or random self-cuing
for on-task behavior).
Observation Student is responsible for monitoring the target behavior.

Recording Ask student best way to record the presence or absence of

the target behavior.

Evaluation Student is at least partially responsible for determining

when the goal was met (may include a system for verifying
accuracy).

Administration of Student gives him- or herself points or tokens for exhibiting

secondary reinforcers target behavior.

Administration of When the student has accumulated enough points or tokens,

primary reinforcers he or she chooses reward from reinforcement menu.

Monitoring Student is responsible for charting or graphing performance

over time.

From Executive Skills in Children and Adolescents, Third Edition, by Peg Dawson and Richard Guare. Copyright © 2018
The Guilford Press. Permission to photocopy this form is granted to purchasers of this book for personal use or use with
students (see copyright page for details).
 FORM 5.2

Forms for Developing Behavior Plans/Incentive Systems

A. Incentive Planning Sheet

Problem Behavior

Goal

Possible Rewards

Daily Weekly Long Term

Possible Contingencies

(continued)

From Executive Skills in Children and Adolescents, Third Edition, by Peg Dawson and Richard Guare. Copyright © 2018
The Guilford Press. Permission to photocopy this form is granted to purchasers of this book for personal use or use with
students (see copyright page for details).
 Forms for Developing Behavior Plans/Incentive Systems (page 2 of 2)

B. Contract
Child agrees to:

To help child reach goal, parents or teacher(s) will:

Child will earn:

If child fails to meet agreement, child will:

 FORM 6.1

Morning Routine Checklist

Check
Task When Done
Hang up coats/outerwear in appropriate place

Get out homework and place on right upper corner of desk

Sharpen pencils and gather other materials needed for the first class

Check the blackboard for instructions

Follow instructions

From Executive Skills in Children and Adolescents, Third Edition, by Peg Dawson and Richard Guare. Copyright © 2018
The Guilford Press. Permission to photocopy this form is granted to purchasers of this book for personal use or use with
students (see copyright page for details).
 FORM 6.2

End-of-Day Routine Checklists

End-of-Day Routine—Checklist 1

Packed
Materials needed in bag
Assignment book filled in

Spelling workbook

Reading book

Reading folder

Social studies book

Social studies folder

Science book

Science folder

Math book

Math folder

Other (permission slips, notices, etc.):

Signed: Date:

(continued)

From Executive Skills in Children and Adolescents, Third Edition, by Peg Dawson and Richard Guare. Copyright © 2018
The Guilford Press. Permission to photocopy this form is granted to purchasers of this book for personal use or use with
students (see copyright page for details).
 End-of-Day Routine Checklists (page 2 of 2)

End-of-Day Routine—Checklist 2

Check When
Steps to Follow Done
Hand in any homework assignments completed

Hand in any in-class assignments completed

Return any materials borrowed from classmates or teacher

Tidy up desk surface; check floor around desk

Gather all necessary materials to go home

1—Books
2—Notebooks
3—Folders
4—Assignment book
5—Worksheets
6—Slips/notices for parents
7—Clothing (hat, mittens, coat)
8—Gym clothes
9—Other
Place appropriate materials in backpack

Ask myself, Am I forgetting anything?

From Executive Skills in Children and Adolescents, Third Edition, by Peg Dawson and Richard Guare. Copyright © 2018
The Guilford Press. Permission to photocopy this form is granted to purchasers of this book for personal use or use with
students (see copyright page for details).
 FORM 6.3

Daily Homework Planner

Date:

Do I have all the How long do you How long did

Subject/assignment materials? Do I need help? think it will take? Start time Stop time it take?

Yes No Yes No

Yes No Yes No

Yes No Yes No

Yes No Yes No

Yes No Yes No

Yes No Yes No

From Executive Skills in Children and Adolescents, Third Edition, by Peg Dawson and Richard Guare. Copyright © 2018 The Guilford Press. Permission to photocopy this form is
granted to purchasers of this book for personal use or use with students (see copyright page for details).
 FORM 6.4

Attention-Monitoring Checklist

Date:
Time:
Class activity:

Was I paying attention?

YES NO

From Executive Skills in Children and Adolescents, Third Edition, by Peg Dawson and Richard Guare. Copyright © 2018
The Guilford Press. Permission to photocopy this form is granted to purchasers of this book for personal use or use with
students (see copyright page for details).
 FORM 6.5

Desk Cleaning Checklist

STEP 1: GATHER NECESSARY MATERIALS

Check all
Materials needed that apply
Wastebasket

Empty file folders

Three-ring binders

Paper clips

Stapler

Manila envelopes

STEP 2: FOLLOW DESK-CLEANING PROCEDURE

Check
Procedure when done
Empty out desk.

Sort everything into two piles: Save/Don’t Save.

Throw Don’t Save pile in wastebasket.

Sort Save Pile into two piles:

1. School stuff (books, unfinished assignments, assignments that are completed but
the teacher wants me to save, pens, pencils, etc.)
2. Home stuff (notices/slips to give Mom, assignments I want to save but don’t have
to keep for teacher, uneaten snacks, etc.)

Put “home stuff” in backpack to go home (in folders or manila envelopes if necessary).

Sort school stuff: one pile for incomplete homework assignments, one pile for each
subject (not current homework), one extra pile for “other.”
Organize each subject pile following teacher instructions (e.g., placing materials by
date in three-ring binders or folders).
Decide what to do with the “other” pile.

Put all school materials neatly back in desk.

From Executive Skills in Children and Adolescents, Third Edition, by Peg Dawson and Richard Guare. Copyright © 2018
The Guilford Press. Permission to photocopy this form is granted to purchasers of this book for personal use or use with
students (see copyright page for details).
 FORM 6.6

Writing Template for a Five-Paragraph Essay

Introductory Paragraph
Sentence 1 summarizes what your essay is about:

Sentence 2 focuses in on the main point you want to make:

Sentence 3 adds more detail or explains why the topic is important:

Body Paragraphs
Paragraph 1, topic sentence:

Supporting detail 1:

Supporting detail 2:

Supporting detail 3:

Paragraph 2, topic sentence:

Supporting detail 1:

Supporting detail 2:

Supporting detail 3:

(continued)

From Executive Skills in Children and Adolescents, Third Edition, by Peg Dawson and Richard Guare. Copyright © 2018
The Guilford Press. Permission to photocopy this form is granted to purchasers of this book for personal use or use with
students (see copyright page for details).
 Writing Template for a Five-Paragraph Essay (page 2 of 2)

Paragraph 3, topic sentence:

Supporting detail 1:

Supporting detail 2:

Supporting detail 3:

Concluding Paragraph
Restate the most important point from the paper you want to make (what the reader should
go away understanding):
 FORM 6.7

Long-Term Project-Planning Sheet

STEP 1: SELECT TOPIC

What are possible topics? What I like about this choice: What I don’t like:
1.

2.

3.

4.

5.

Final Topic Choice:

STEP 2: IDENTIFY NECESSARY MATERIALS

What materials or resources

do you need? Where will you get them? When will you get them?

1.

2.

3.

4.

5.

(continued)

From Executive Skills in Children and Adolescents, Third Edition, by Peg Dawson and Richard Guare. Copyright © 2018
The Guilford Press. Permission to photocopy this form is granted to purchasers of this book for personal use or use with
students (see copyright page for details).
 Long-Term Project-Planning Sheet (page 2 of 2)

STEP 3: IDENTIFY PROJECT TASKS AND DUE DATES

When will you Check off

What do you need to do? (List each step in order) do it? when done
Step 1:

Step 2:

Step 3:

Step 4:

Step 5:

Step 6:

Step 7:

Step 8:

Step 9:

Step 10:

Reminder List
Include here any additional tasks or details you need to keep in mind as you work on the project. Cross
out or check off each one as it is taken care of.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
 FORM 6.8

Tools for Studying

A. Menu of Study Strategies
Check off the ones you will use.
Passive strategies Active strategies with feedback
(use sparingly) Active strategies (better) (best)
1. Reread text 7. Make study guide 13. Quiz myself with Quizlet/
2. Reread notes 8. Make flashcards/Quizlet study guide/flash cards
3. Highlight notes/text 9. Make concept maps 14. Take practice test
(check answers)
4. Ready study guide 10. Organize notes
15. Re-do old tests or homework
5. Rewrite notes 11. Complete review packet (check answers)
6. Read/watch Spark (no answers)
16. Have someone else quiz me
Notes, Khan 12. Attend review session or
Academy, etc. study group 17. Complete review packet
(check answers)
18. Meet 1:1 with teacher
19. Other:

B. Study Plan

Date Day Which strategies will I use? (write #) How much time for each strategy?
4 days 1. 1.
before test 2. 2.
3. 3.

3 days 1. 1.
before test 2. 2.
3. 3.
2 days 1. 1.
before test 2. 2.
3. 3.
1 day 1. 1.
before test 2. 2.
3. 3.

C. Posttest Evaluation
How did your studying work out? Answer the following questions:
1. What strategies worked best? 2. What strategies were not so helpful?
3. Did you spend enough time studying? Yes No
4. If no, what more should you have done? 5. What will you do differently the next time?

From Executive Skills in Children and Adolescents, Third Edition, by Peg Dawson and Richard Guare. Copyright © 2018
The Guilford Press. Permission to photocopy this form is granted to purchasers of this book for personal use or use with
students (see copyright page for details).
 FORM 6.9

Organizing Notebooks/Homework
A. Setting Up a Notebook/Homework Management System

Got it
System element What will you use? (9)
Place for unfinished
homework

Place for completed

assignments

Place to keep materials for

later filing

Notebooks or binder(s) for

each subject

Other things you might need:

1.
2.
3.
4.

B. Maintaining a Notebook/Homework Management System

Task Monday Tuesday Wednesday Thursday Weekend

Clean out “to be filed” folder

Go through notebooks and

books for other loose papers
and file them

Place all assignments (both

finished and unfinished) in
appropriate places

From Executive Skills in Children and Adolescents, Third Edition, by Peg Dawson and Richard Guare. Copyright © 2018
The Guilford Press. Permission to photocopy this form is granted to purchasers of this book for personal use or use with
students (see copyright page for details).
 FORM 6.10

Note-Taking Template: Cornell Method

Date: Class:
Lecture Topic:

Reflections, questions, links

Key terms and concepts Running notes to personal experience

From Executive Skills in Children and Adolescents, Third Edition, by Peg Dawson and Richard Guare. Copyright © 2018
The Guilford Press. Permission to photocopy this form is granted to purchasers of this book for personal use or use with
students (see copyright page for details).
 FORM 6.11

Hard Times Board

Triggers: What makes me mad

Can’t dos

When I’m having a hard time, I can take a break and

From Executive Skills in Children and Adolescents, Third Edition, by Peg Dawson and Richard Guare. Copyright © 2018
The Guilford Press. Permission to photocopy this form is granted to purchasers of this book for personal use or use with
students (see copyright page for details).
 FORM 6.12

Maintaining Self-Control
The things I do without thinking include

Common situations where I act without thinking are

What I will do to stay controlled

From Executive Skills in Children and Adolescents, Third Edition, by Peg Dawson and Richard Guare. Copyright © 2018
The Guilford Press. Permission to photocopy this form is granted to purchasers of this book for personal use or use with
students (see copyright page for details).
 FORM 6.13

Worry Board
I get worried when . . .

When I get nervous . . .

When I’m feeling nervous I can . . .

From Executive Skills in Children and Adolescents, Third Edition, by Peg Dawson and Richard Guare. Copyright © 2018
The Guilford Press. Permission to photocopy this form is granted to purchasers of this book for personal use or use with
students (see copyright page for details).
 FORM 6.14

Managing Changes in Plans or Schedules

A. Surprise! Card
Date:

Time Activity

Surprise:

B. Complaint Form
Date:

Nature of Complaint:

Why You Think the Situation Was Unfair:

What You Wish Had Happened:

From Executive Skills in Children and Adolescents, Third Edition, by Peg Dawson and Richard Guare. Copyright © 2018
The Guilford Press. Permission to photocopy this form is granted to purchasers of this book for personal use or use with
students (see copyright page for details).
 FORM 6.15

Learning Not to Cry over Little Things

A. Upset Log

Date Time Duration of upset Precipitating event

B. Contract
Here’s what I can do instead of crying:

Here’s what will happen if I can keep from crying when I’m upset:

Here’s what will happen when I cry over little things:

From Executive Skills in Children and Adolescents, Third Edition, by Peg Dawson and Richard Guare. Copyright © 2018
The Guilford Press. Permission to photocopy this form is granted to purchasers of this book for personal use or use with
students (see copyright page for details).
 FORM 6.16

Solving Problems Worksheet

What is the problem?

What are some possible things I (we) could do to solve the problem?

What will I (we) try first?

If this doesn’t work, what can I (we) do?

How did it go? Did my (our) solution work?

What might I (we) do differently the next time?

From Executive Skills in Children and Adolescents, Third Edition, by Peg Dawson and Richard Guare. Copyright © 2018
The Guilford Press. Permission to photocopy this form is granted to purchasers of this book for personal use or use with
students (see copyright page for details).
 FORM 10.1

Class Roster for Teams and Coaches

Team Orange M T W T F Total Team Purple M T W T F Total

Reprinted from Dawson and Guare (2012). Copyright © The Guilford Press.

From Executive Skills in Children and Adolescents, Third Edition, by Peg Dawson and Richard Guare. Copyright © 2018
The Guilford Press. Permission to photocopy this form is granted to purchasers of this book for personal use or use with
students (see copyright page for details).
 FORM 10.2

Score Sheet for Math Facts Goal

Student: Coach:

Rating Rating
Self Coach Job Self Coach

1 2 3 1 2 3 Has materials 1 2 3 1 2 3

1 2 3 1 2 3 Stays on job 1 2 3 1 2 3

Completes job
1 2 3 1 2 3 1 2 3 1 2 3
(on time/with correction)

1 2 3 1 2 3 Meets goal 1 2 3 1 2 3

Has materials:
3 = Has pencil, math facts sheet, work folder
2 = Missing one of above
1 = Missing two or more of above

Stays on job:
3 = Completes tasks without reminder
2 = Needs one reminder from coach
1 = Needs reminder from teacher after coach

Completes job and meets goal:

3 = Improves on previous day’s performance
2 = Gets same score as yesterday
1 = Gets lower score than yesterday

Reprinted from Dawson and Guare (2012). Copyright © The Guilford Press.

From Executive Skills in Children and Adolescents, Third Edition, by Peg Dawson and Richard Guare. Copyright © 2018
The Guilford Press. Permission to photocopy this form is granted to purchasers of this book for personal use or use with
students (see copyright page for details).
 FORM 10.3

Score Sheet for Independent Work Time

Student: Coach:

Rating Rating
Self Coach Job Self Coach

1 2 3 1 2 3 Listens to direction 1 2 3 1 2 3

1 2 3 1 2 3 Stays in seat 1 2 3 1 2 3

1 2 3 1 2 3 Stays on job 1 2 3 1 2 3

1 2 3 1 2 3 Completes job or asks for help 1 2 3 1 2 3

Listens to directions:
3 = Starts work immediately
2 = Needs directions from coach
1 = Needs directions from teacher

Stays in seat:
3 = Stays in seat—no reminder
2 = Leaves seat once—returns with coach cue
1 = Leaves seat more than once

Stays on job
3 = Attends to job—no reminder
2 = Needs one reminder from coach
1 = Needs reminder from teacher after coach

Completes job:
3 = Finishes all work
2 = Finishes most of work
1 = Finishes only a little work

Reprinted from Dawson and Guare (2012). Copyright © The Guilford Press.

From Executive Skills in Children and Adolescents, Third Edition, by Peg Dawson and Richard Guare. Copyright © 2018
The Guilford Press. Permission to photocopy this form is granted to purchasers of this book for personal use or use with
students (see copyright page for details).
 FORM 10.4

Score Sheet for Morning Meeting Behaviors

Student: Coach:

Rating Rating
Self Coach Job Self Coach

1 2 3 1 2 3 Listens to speaker 1 2 3 1 2 3

1 2 3 1 2 3 Raises hand to speak 1 2 3 1 2 3

1 2 3 1 2 3 Sits in space 1 2 3 1 2 3

1 2 3 1 2 3 Follows directions 1 2 3 1 2 3

3 = No reminders
2 = One reminder from coach
1 = Two or more reminders from coach or one from teacher

Reprinted from Dawson and Guare (2012). Copyright © The Guilford Press.

From Executive Skills in Children and Adolescents, Third Edition, by Peg Dawson and Richard Guare. Copyright © 2018
The Guilford Press. Permission to photocopy this form is granted to purchasers of this book for personal use or use with
students (see copyright page for details).
 FORM 10.5

Score Sheet for End-of-Day Routine

Student: Coach:

Rating Rating
Self Coach Job Self Coach

1 2 3 1 2 3 Desk cleared off/wiped 1 2 3 1 2 3

Tools (e.g., pencils) in

1 2 3 1 2 3 1 2 3 1 2 3
containers

1 2 3 1 2 3 Folders in correct area 1 2 3 1 2 3

Notices and homework

1 2 3 1 2 3 1 2 3 1 2 3
materials in backpack

Desk cleared off/wiped:

3 = No materials or substances on desk
2 = One object on desk or top not clean
1 = Objects out and top not clean

Tools in containers:
3 = All personal items stored
2 = One item left out
1 = Two or more items left out

Folders in correct area:

3 = Folders (e.g., writing, math) in correct area
2 = One folder out
1 = Two or more folders out or missing

Notices and homework materials in backpack:

3 = All materials in backpack
2 = One notice or homework sheet missing
1 = More than one notice or worksheet not in backpack or missing

Reprinted from Dawson and Guare (2012). Copyright © The Guilford Press.

From Executive Skills in Children and Adolescents, Third Edition, by Peg Dawson and Richard Guare. Copyright © 2018
The Guilford Press. Permission to photocopy this form is granted to purchasers of this book for personal use or use with
students (see copyright page for details).