STUDENT ASSISTANCE PROGRAM (SAP)
BEHAVIOR OBSERVATION FORM
______ Initial Referral by _________________Date________
______ Staffed at SAP Core Team__________Date________
______ Information Gathering_____________Date________
______ Follow-up/ Review_________________Date________
______ Case Manager (Mentor)_________________________
Student _____________________________________
Observer ________________________________________________
Grade
_____________________________________
Dates of Observation ______________________________________
Period you have student _______________________
Return to C/M (Mentor) ___________________________________
Reason for referral:
____ Academic
____ Behavioral
____ Social/Emotional
______Both
_____IEP
_____504
Please check all that apply:
ACADEMICS
___ Lower grades-lower
achievement
___ Academic failure
___ Always behind in class
___ Lack of motivation-apathy
___ Drop in grades
___ Lacking English skills
___ Easily frustrated/ gives up
___ SAVE
___ Cheating
___ Other____________________
SCHOOL ATTENDANCE
___ # of absences to date:_______
___ # of tardies to date: ________
___ Frequently requesting to be out
of class (i.e. trips to restroom,
etc.)
HEALTH ISSUES
___ Stomach problems
___ Frequent visit to nurse
___ Physical complaints
___ Other______________________
STRENGTHS
___ Works well independently
___ Creative
___ Displays leadership ability
___ Curious
___ Attentive
___ Cooperative
___ Attention to exactness & details
___ Keen insight in problem solving
___ Skilled in divergent thinking
___ Accepts suggestions
___ Appears self-confident
___ Frequently contributes to class
___ Popular with classmates
___ Happy, easy going
___ Courteous
___ Does assignments promptly
___ Effective group participant
___ Communicates well in groups
___ Expresses thoughts well
___ Involved in sports
___ Involved in Extracurricular
Activities
___ Other ____________________
SUBSTANCE ABUSE/ DRUGS
FAMILY CONCERNS
___ Divorce (as of _____________)
___ Past/ Present DSS Involvement
___ Past/ Present Homelessness
___ Unemployment
___ Lack of Parent Supervision
___ Home problems of concern
______________________
___ Parent incarcerated
___ Other _____________________
___ Alcohol
___ Marijuana
___ Prescription Drugs
___ Drowsy
___ Dilated Pupils
___ Talks freely about drug/ alcohol
use
BEHAVIORAL CONCERNS
___ Constant defiance of rules
___ Frequent discipline referrals/
Action ISS or OSS
___ Bully
___ Fighting
___ Does not accept responsibility
___ Acts defensive
___ Depressive-like behavior
___ Bullied
___ Withdrawn (loner)
___ Frequent crying
___ Excessive forgetfulness
___ Frequently tired
___ Loss of Interest in Sports
or Extracurricular Activities
___ Increasing non-involvement
___ Erratic behavior/mood swings
___ Change in friends
___ Change in appearance
___ Anxious/nervous
___ OCD type behavior____________
___ Older social group
___ Cutting
___ Promiscuous Dress
___ Attention-seeking
___ Low self-esteem
___ Friendship Issues
___ Involvement in mediations
___Socially awkward
___ ADD/ADHD
___ Impulsivity
___ Acts without thinking
___ Can’t sit still
___ Daydreams
___ Does not pay attention
___ Other __________________
ADDITIONAL COMMENTS:
__________________________________________________________________________________________
__________________________________________________________________________________________
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