It is a modified version of the ESQ developed by Dawson and Guare and described in a number of their books on executive skills (e.g., Executive Skills in Children and Adolescents, Smart but Scattered, Smart but Scattered Teens).
Executive Skills Questionnaire – Revised(ESQ-R)
Miind My Miind > Professional Assessment > Dawson and Guare > Executive Skills Questionnaire – Revised(ESQ-R)