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5312.1-E, Drug and Alcohol Abuse Exhibit

The following form requests that you report actual observed behavior of a student. This will be used to assist in the evaluation of the student’s needs, and to help in determining an appropriate plan of action.

If requested, information contained in this form will be made available to the student or parent/guardian.

STUDENT ___________________________________________________ DATE _________
GRADE ______ OBSERVER ___________________________________________________

Please check behaviors exhibited by the student:

    ____ frequently absent/truant
    ____ frequently tardy
    ____ skips class
    ____ detention suspension
    ____ frequent schedule change requests
    ____ frequent nurse visits
    ____ frequent counselor visits
    ____ increase in disciplinary action
    ____ frequently asks to be excused from class
    ____ attendance at extra-curricular activities sporadic
    ____ dropped out of extra-curricular activities

    ____ sudden drop in grades and/or achievement levels
    ____ gradual lowering of grades and/or achievement levels
    ____ lack of motivation, apathy
    ____ present in class but inattentive
    ____ lack of response to concern expressed by teacher regarding any of the above

    ____ poor hygiene
    ____ neglect of personal appearance
    ____ nervous, agitated, trouble sitting still
    ____ eyes often bloodshot, dull, or glassy (frequent use of eye drops)
    ____ coordination impaired
    ____ burns on hands, clothing
    ____ extreme change in weight
    ____ physical complaints
    ____ frequent trips to the bathroom
    ____ frequent physical injuries, bruises
    ____ odor of alcohol or marijuana
    ____ sleeping in class
    ____ withdrawal from peers and staff
    ____ confused, disoriented
    ____ inappropriate laughter
    ____ mood swings
    ____ fighting with peers/staff
    ____ talks freely about drug use
    ____ appears depressed
    ____ appears anxious, fearful
    ____ lethargic attitude

    ____ verbal abuse toward staff/peers
    ____ does not follow through with commitments
    ____ defiance of rules
    ____ defensiveness/denying/blaming
    ____ obscene language, gestures
    ____ dramatic attention getting
    ____ fighting
    ____ cheating


June 23, 1986
January 26, 1998