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Depressed/withdrawn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Withdrawn/unresponsive to teacher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