1. Jika anak dipanggil, atau dipanggil namanya, reaksi anak : anak
diam/menoleh/melihat/menyahut, apa yang dikatakannya................................................................................................................... ......................................................................................................................................... Sikap anak (misal datang mendekat) .......................................................................................................................................... ……………………………………………………………………………………………………………………………………. 2. Apakah anak paham jika diinstruksi untuk melakukan sebuah tugas? Ya/tidak Reaksi anak (misal diam) .......................................................................................................................................... ……………………………………………………………………………………………………………………………………. 3. Apakah anak paham jika diajak berkomunikasi? Ya/tidak Reaksi anak .......................................................................................................................................... ……………………………………………………………………………………………………………………………………. 4. Apakah anak bisa memegang pensil? Tepat/tidak tepat Jelaskan .......................................................................................................................................... .......................................................................................................................................... 5. Apakah anak bisa membaca? Bisa/tidak Jelaskan .......................................................................................................................................... .......................................................................................................................................... 6. Apakah anak bisa menulis? Tulisan jelas/tidak jelas Jelaskan .......................................................................................................................................... .......................................................................................................................................... 7. Apakah anak bisa berhitung sederhana? Bisa/tidak bisa Jelaskan .......................................................................................................................................... .......................................................................................................................................... 8. Apakah anak bisa dikte? Bisa/tidak bisa Jelaskan .......................................................................................................................................... ..........................................................................................................................................