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:
- ATTENDANCE
____ 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 - ACADEMIC ACHIEVEMENT
____ 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 - PHYSICAL/PSYCHOLOGICAL CONDITION
____ 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 - DISRUPTIVE BEHAVIOR
____ 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
COMMENTS:
June 23, 1986
January 26, 1998