Child Occupational Self Assessment (COSA) – Page 1
Child Occupational Self Assessment (COSA)
Youth Rating Form with Symbols
Name: _____________________ Gender: M F Date of Birth: ____ /____ /____
Therapist: ______________________________ Assessment Date: ____ /____ /____
Directions: Here are some sentences that tell about everyday things that young people do. For each
one, ask yourself, “Is this a problem for me? If so, how much of a problem is it for me?” Mark the
face (s) that best matches how you feel.
Also think about how important things are to you. Please tell how important these items are to you,
not your parents or teachers. Mark the number of stars that best matches how important something
is to you.
There are no right and wrong responses. This is not a test. I want to know what response best
describes how you feel about these activities. Let’s try an example:
I have a I have a Most
I am really Not really Really
big little I do this Important important
Myself good at important important
problem problem ok to me of all to
doing this to me to me
doing this doing this me
Watch TV or a
video
Child Occupational Self Assessment (COSA) – Page 2
I have a I have a Most
I am really Not really Really
big little I do this Important important
Myself good at important important
problem problem ok to me of all to
doing this to me to me
doing this doing this me
Keep my body
clean
Dress myself
Eat my meals
without any
help
Buy something
myself
Get my chores
done
Child Occupational Self Assessment (COSA) – Page 3
I have a I have a Most
I am really Not really Really
big little I do this Important important
Myself good at important important
problem problem ok to me of all to
doing this to me to me
doing this doing this me
Get enough
sleep
Have enough
time to do
things I like
Take care of
my things
Get around
from one place
to another
Choose things
that I want to
do
Child Occupational Self Assessment (COSA) – Page 4
I have a I have a Most
I am really Not really Really
big little I do this Important important
Myself good at important important
problem problem ok to me of all to
doing this to me to me
doing this doing this me
Keep my mind
on what I am
doing
Do things with
my family
Do things with
my
friends
Do things with
my
classmates
Follow
classroom rules
Child Occupational Self Assessment (COSA) – Page 5
I have a I have a Most
I am really Not really Really
big little I do this Important important
Myself good at important important
problem problem ok to me of all to
doing this to me to me
doing this doing this me
Finish my work
in class on time
Get my
homework done
Ask my teacher
questions when
I need to
Make others
understand my
ideas
Think of ways
to do things
when I have a
problem
Child Occupational Self Assessment (COSA) – Page 6
I have a I have a Most
I am really Not really Really
big little I do this Important important
Myself good at important important
problem problem ok to me of all to
doing this to me to me
doing this doing this me
Keep working
on something
even when it
gets hard
Calm myself
down when I
am upset
Make my body
do what I want
it to do
Use my hands
to work with
things
Finish what I
am doing
without getting
tired too soon
Child Occupational Self Assessment (COSA) – Page 7
COSA Follow-up Questions:
What are 2 other things you are really good at doing that we didn’t talk about today?
1) _________________________________________________________________________________________________________
2) _________________________________________________________________________________________________________
What are 2 other things you have a big problem doing that we didn’t talk about today?
1) _________________________________________________________________________________________________________
2) _________________________________________________________________________________________________________
Is there anything else that is important to you that we didn’t get to talk about?
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
