Name: ____________________
Date: _________________
Responsibility Awareness
Level 0
Irresponsible
o Blames
Others
o Makes
Excuses
o Disrupts the
class
o Doesn’t
Listen
o Doesn’t
Participate
Level 1
Self Control
o Listens some
of the time
o Participates
some of the
time
o Doesn’t put
in effort
o Doesn’t
disrupt the
class
Level 2
Effort &
Cooperation
Level 3
Self-Direction
Level 4
Leadership
o Listens all of
the time
o Stays on task
most of the
time.
o Participates
most of the
time
o Listens all of
the time
o Stays on task
all of the
time.
o Participates
all of the time
o Shows
respect to
others
o Makes good
choices
o Admits
mistakes and
apologizes
o Works to
settle
arguments
without the
teacher’s
help
o Listens all of
the time
o Stays on task
all of the
time.
o Participates
all of the
time.
o Makes good
choices
o Admits
mistakes and
apologizes
o Helps other
students
when they
need it
1. Explain why you participated at that level today.
2. How can you participate at a higher level next class? If level 0 provide a
consequence for your action, and if level 4 provide actions to take it outside of
class?
Teacher Signature: ______________________________________________
Layne Sanderson ©
Name: ____________________
Date: _________________
Emoji Clip Art: https://www.teacherspayteachers.com/Product/Emoji-Clipart-80Emoticons-and-Smiley-Faces-Back-To-School-4790328
Font: Orange Juice http://brittneymurphydesign.com/downloads/orange-juice/
Other Sources:
Hellison, D. R. (2011). Teaching personal and social responsibility through physical
activity. Champaign, IL: Human Kinetics.
Layne Sanderson ©