Instructions to Group Workers Using this Form:

The rating scale should be filled out on all members of your school program group (or groups), with 8 weeks of enrollment for the current program year. It is intended to provide a global impression of the kinds of vulnerability or troubles experienced by children served by the program. It is not meant as a diagnostic tool for individual children.

For each child, you will be asked to rate whether that child has no, moderate, or significant vulnerability in each of four areas: academic, family, social, psychological. The list identifies some indicators of vulnerability or troubles in each of these domains. You may think of others. The ratings should depend on your judgment, both your knowledge of a child and your observations of that child in the center and other settings.

Suggested Steps:

1. CIRCLE the indicators listed that apply to a particular child, and note any other indicators in the space marked "Other Indicators."
   
   
2. CIRCLE your rating (no, moderate, or significant) by considering both the number and the importance of indicators circled in each area for that child. In general, one or two indicators suggest moderate vulnerability, three or more indicators significant vulnerability. But the presence of two indicators can mean significant vulnerability as well, if you believe them to be serious.
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Center:
Group Worker:
Child's Initials:
Child's Age:

Indicators (circle your observations):

(Consider each indicator in relation to a child's age.)

Social:

1. child fights with other children;
2. child bullies other children;
3. child is shy, avoids contact with other children;
4. child is not good at getting the attention of others (including adults);
5. child does not communicate needs effectively;
6. child picked on or scapegoated by peers;
7. child appears to have no friends;
8. child is member of street gang;
9. child needs a lot of supervision or structuring;
10. child unable to use adults as a resource to solve problems;
11. other indicators:

Academic:

1. child retained in grade or special education placement;
2. child has difficulties doing school work or homework;
3. child lacks interest in after school program educational support activities;
4. child has poor school attendance;
5. child does not enjoy school;
6. child needs remediation in reading or math;
7. child referred to after school program by school staff;
8. child being tutored in school by CTC staff;
9. child has short attention span and/or trouble concentrating on academic work;
10. other indicators:

Psychological:

1. child frequently appears withdrawn or preoccupied;
2. child is persistently oppositional in behaviour, unwilling to follow directions;
3. child overly aggressive in behaviour;
4. child frequently appears anxious;
5. child lacks self-confidence;
6. child lacks self-control;
7. child frequently appears angry;
8. child has run away from home or talked of leaving home;
9. child uses drugs;
10. other indicators:

Family:

1. family history of involvement with protective services;
2. child or siblings has been removed from home in past or present;
3. drug or alcohol abuse in child's family;
4. single parent family;
5. child lacks supervision from parent(s);
6. family appears chaotic/disorganized;
7. family members with serious health problems;
8. recent death in family;
9. parents recently divorced;
10. parent(s) not interested in child's activities;
11. child's physical appearance or hygiene indicate parental inattention;
12. child or siblings have run away from home;
13. other indicators:

Now complete this form by circling the vulnerability scale: