Student:_______________________________________________________ Grade: ____________
Teacher: __________________________________ Reason: _______________________________________
Date: _____________ Time:________________ Subject: _________________________
Position of student in class: _____________________________________________________________
Behavior
Tries Hard Completes assigned work
Gives up easily Does not complete assigned work
Works at reasonable pace
Works carefully Works slowly
Careless in work
Attentive to lesson/task
Begins work independently Inattentive to lesson/task - typical length of attention
Hesitant to begin working (Ex. 2 min., 5 min.) ___________
Looking around room
Asks appropriate questions Plays with materials
Does not ask appropriate questions Stares blankly
Does not ask Doodles
Asks irrelevant or inappropriate ?s
Follows directions
Volunteers answer Does not follow direction
When called upon, gives correct answer Does not understand
Attends to others when they give answers Did not pay attention
Refusal
Knows appropriate place in text
Loses place Student is aware of observer
Student knows observer is watching him/her
Materials appear organized
Workspace is messy/chaotic
Level of Energy Affect/Mood
Lots of energy (fidgets, squirms, tilts chair) Happy
Appropriate level of activity Depressed/withdrawn
Lethargic Angry/hostile
Stays in seat during lesson Anxious
Is out of seat during lesson Easily upset
Makes noises Apathetic
Talks out of turn Bored
Relationship with peers Relationship with teacher
Leader in group work or play Cooperative
Participates in group work or play Seeks adult attention (+/-)
Onlooker in group work or play Disrespectful to teachers
Interactions are appropriate Requires teacher support for majority of tasks
Exhibits distracting behaviors with peers Withdrawn/unresponsive to teacher
Aggressive toward other students Argues with teacher
Argues with peers
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