Please start the SIS Ages 2 to 5 Survey

Trainer's E-mail Address (if submitting as part of a specific training program.):

Parent's First Name:

Parent's Last Name:

Parent's Email Address:

Child's First Name:

Child's Last Name:

Child's Age:

Student's Gender :

MaleFemale

Your Relationship to Child :

Parent/GuardianSchool TeacherRelativeReligious TeacherFamily FriendCoachOther

Child's City:

Child's State/Province:

Child's Country :

Name of organization hosting the training program (if known):

RESPONDER QUESTIONS

1. Does the child tend to persuade or be persuaded by peers?

Frequently persuades othersCommonly persuades othersSometimes is persuaded; sometimes persuades othersUsually more persuaded by othersNearly always influenced by othersUnsure

2. The child enjoys staying busy with tasks.

Very littleLittleSomeOftenVeryUnsure

3. The child is observed to be opinionated/strong-willed.

Is very strong-willed/opinionatedOffers unsolicited opinionsHas opinions when askedIs compliantIs very compliantUnsure

4. The child enjoys role playing with peers, establishing himself/herself in more adult-leader roles (i.e. the teacher, parent, doctor, boss).

Very littleA littleSomeQuite a bitA lotUnsure

5. Peers seem to like and follow child (on the playground, in the classroom, in the neighborhood).

Not to my knowledgeRarelyOccasionallyQuite a bitVery oftenUnsure

6. This child has been disciplined / critiqued for being “bossy,” may interrupt an adult giving instructions with a better way of accomplishing a task.

Not this childJust normal kid stuffSometimesCertainlyMost certainlyUnsure

7. This child sticks to his/her principles, even when peers deviate or disagree.

Not at allUsually notSometimesUsuallyNearly alwaysUnsure

8. Child initiates new projects and tasks.

FrequentlyQuite a bitSomeVery littleNoUnsure

9. The child shows disappointment when s/he is unable to finish tasks, cannot share ideas, is not called upon.

FrequentlyQuite oftenSometimesRarelyNot at allUnsure

10. Child enjoys being the teacher’s helper and/or you would trust this child to be a team helper, assisting you in organizing and overseeing a project to completion.

Not likelyPerhapsFor a short timeYesConfidently yesUnsure

11. The child works to get his/her way.

Often succeeds with adultsSucceeds with peers / compromises with adultsCompromise with peersObjects, then gives inCompliant / coalescesUnsure

12. Child is decisive.

Decision making seems painful / prefers to defer to othersTakes a long time to decide / may procrastinateDecides quickly / may waffle afterwardDecides well for the most partGathers info & input from others, then decides with confidenceUnsure

13. When child speaks:

Others tend to ignore / continue with conversationOthers correct / reprove child for interruptingOthers partially listenOthers “give the floor” / listenOthers listen and often heed child / move to his/her agendaUnsure

14. Child exudes confidence.

Confidence is high, but generally realisticOverly confidentConfidence is moderateConfidence is lowLacks confidence / feels great stressUnsure

15. Child is a good problem solver, can tell when something isn’t working and strives to rethink it.

Not noticeableLittleSomeFrequentlyFrequently along with encouragement and affirmation of othersUnsure

16. Child initiates games or activities with others.

Tends not to initiate games or activities; plays aloneTends not to initiate games or activities; followsWhen initiates games or activities, peers may or may not followPeers and younger kids seek out child and followPeers and older kids seek out child and followUnsure

17. Child remains enthusiastic and optimistic, even during challenges.

Determined and hopeful even when challengedPositiveEven-temperedWorrisome if challenged with new, big tasksPessimistic / tends to see the downside of situationsUnsure

18. Use of humor and sometimes the “class clown”.

Able to distract peers’ attention from adultsAble to distract attention from other peersPeers acknowledge, occasionally respond toPeers notice, but tend to dismissPeers tend to ignore or find humor irritatingUnsure

19. Exudes a can-do attitude and perseveres.

Resists new challenges / verbalizes reasons to give up before startSeems to quietly feel self-doubts / procrastinates oftenAttempts new challenges, but tends to give up when faces difficultiesDoesn’t quit easily / perseveresPerseveres doggedly and inspires others with example to do sameUnsure

20. Child is willing to takes risks, try new things.

Avoids risk taking / seems fearfulOnly takes very safe risksTakes moderate risks if encouraged by trusted othersOverly courageous / needs to be subdued, dissuaded at timesPushes the boundaries and takes sensible risksUnsure

21. Child ignores or pushes on the rules if it helps meet his/her goals.

Rarely challenges / very compliantInitially, but not for longFor a while, but passivelyFor a while and activelyStrongly and persistentUnsure

22. Child is not afraid of healthy conflict with peers.

Seems to want peace at all costs / to suffer injusticeTends to want peace and avoids most conflictsIs willing to confront, but backs down with minor conflictWilling to initiate confrontation and respond to injustice personallyWilling to confront a situation and gathers others to do sameUnsure

23. The child is competitive.

VeryModerate to highModerateSomeNot at allUnsure

24. The child provides clear instructions to others in a task, verbally and/or demonstrating what to do.

Seems to find this very difficultNot a lotDoes this somewhatConsistently with simple or medium complex tasksSeems to handle complex tasks and instructions wellUnsure

25. Organizational leadership: the ability to influence others as a group, toward accomplishing common goals. Based on the above definition of organizational leadership, how would you rate the observed organizational leadership qualities of the child?

StrongQuite a bitSomeLittleVery littleUnsure