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Sample Template for Final Assessment of the Strategy

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Date: 4/12/18

Name of Student: Kelly

Executive Function(s) Being Addressed: Initiating, Time Management, Attending

Intervention Implemented? (Describe the Strategy and How It Is Being Used).

The Self-Check Card was used by Kelly initially after an intermittent verbal prompt by the teacher. Kelly later checked her progress based on the use of a timer. At the end of the strategy instruction period, Kelly used the Self-Check Card independently to monitor her progress.

 ☐ Strategy Used From: 3/20/18 To: 4/10/18

 ☑ UDL-EF Process UsedCompleted Executive Function Planning ChartThought through Selecting a Strategy for the Student While Integrating UDL ChartCreated with student a Strategy Implementation With a Focus on UDL and Metacognition ChartField-tested the strategyCreated strategy card for the strategy and placed on the student’s Strategy RingFinalized the strategy and selected this strategy for the studentTaught the Strategy and kept data of usageMade revisions as necessary

 ☑ Data for Measured ResultsData were analyzed and showed that the strategy helped Kelly complete her work on time 12 out of 15 days.

 ☑ Anecdotal Report of ResultsKelly reported that she liked using the Self-Check Card. She was happy to finish her work on time.

 ☑ Review of Results:Kelly began generalizing the use of the Self-Check Card at times when it was not required.

 ☑ Summary Report on Game Plan Progress:Although Kelly has experienced success with this strategy, she will need additional reinforcement in other situations.

Summary Report on Implications of Strategy Use on Academic Skills and Social Interactions (continue on reverse side):

The Executive Function Guidebook

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