Greenville Public School District 2010
Greenville Public School District
Social/Emotional/Behavioral Universal Screener
Student: ___________________________________ School: _____________________________________
Date Completed: ____________________________ Grade: ________________ Period/Block: __________
Completed by: ______________________________ Position: ____________________________________
Directions: Rate each behavior exhibited by the student on a scale from 1 to 5, with “1” indicating a minor
problem and “5” indicating a serious problem. Place a check in the appropriate block. If the student does not
exhibit the behavior, do not check any block and proceed to the next item.
Behaviors
1
Overly active
2
Talks out of turn
3
Disturbs others when they are working
4
Constantly seeks attention
5
Impulsive
6
Acts without thinking of the consequences
7
Lacks self confidence
8
Says “can’t do” without attempting
9
Is overly sensitive
10
Clingy with adults
11
Shy, timid
12
Appears depressed
13
Does not make eye contact
14
Has difficulty making friends
15
Sits alone in cafeteria
16
Appears frightened or worried
17
Cries easily
18
Reports fears or phobias (such as fear of coming to school)
19
Does not recognize danger
20
Pretends to be ill
21
Has poor grooming or personal hygiene
22
Picks at skin, nails
23
Difficulty calming/comforting self
24
Difficulty distinguishing fantasy from reality
25
Makes inappropriate noises
26
Experiences sudden changes in mood
27
Blames or tattles on others
Revised 12-13-2010
1
2
3
4
5
Greenville Public School District 2010
Behaviors
28
Verbally aggressive
29
Teases or bullies others
30
Defiant or stubborn
31
Belligerent toward teachers and/or others in authority
32
Physically aggressive
33
Touches others inappropriately
34
Destroys property
35
Has been caught cheating
36
Has been caught stealing
37
Has cursed school personnel
38
Has threatened to cause harm or has harmed school personnel
39
Has threatened or attempted suicide
40
Has runaway or been on runaway status
41
Tries to cause harm to self
42
Tastes or touches objects when not appropriate
43
Draws inappropriate and/or threatening pictures
44
Writes threatening notes
45
Verbally threatens to cause serious harm to others
46
Does not appear to fit in with other students
47
Hears voices/talks to others who are not there
1
2
3
4
5
If you have concerns about this student that are not addressed by the questionnaire, please explain:
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
Attach any notes, drawings or other information that are pertinent to this student’s social and/or
emotional issues.
Revised 12-13-2010