Finger Windows Assessment
Please complete this form to record and assess performance on the Finger Windows test.
Participant Full Name
*
First Name
Last Name
Participant Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Participant ID (if applicable)
Assessment Date and Time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Test Administrator Name
*
First Name
Last Name
Testing Environment
*
Quiet room
Classroom
Clinic
Home
Other
Assessment Hand Used
*
Right hand
Left hand
Both hands (alternating)
Assessment Instructions Provided to Participant
*
Standardized instructions
Adapted instructions
Finger Windows Trials Results
*
Rows
Correct
Incorrect
No Response
Trial 1
1
2
3
Trial 2
4
5
6
Trial 3
7
8
9
Trial 4
10
11
12
Trial 5
13
14
15
Trial 6
16
17
18
Trial 7
19
20
21
Trial 8
22
23
24
Participant's Attention Level During Assessment
*
Very Low
1
2
3
4
Very High
5
1 is Very Low, 5 is Very High
Observer Comments / Notes
Signature of Participant or Guardian
*
Submit Assessment
Submit Assessment
Should be Empty: