Form A – Behavior Checklist
Behavior Checklist
Student Name: _________________________________________ D.O.B. _________________
Observer: _____________________________________________ Date: ___________________
School: _______________________________________________ Grade: _________________
This form is designed to identify observable behaviors. The teacher should have at least six
weeks experience with the student being observed. Any written documentation of behavior
problems identified below should be attached to the checklist.
Observable Behavior
Always
Sometimes
Never
1. Poor attendance
2. Becomes verbally aggressive when angry
3. Becomes physically aggressive when angry
4. Fights to resolve conflict
5. Asks to see the school nurse
6. Sleeps in class
7. Hyperactive in the morning
8. Hyperactive after lunch
9. Takes medication at school
10. Complies with uniform code
11. Completes classroom assignments
12. Completes homework assignments
13. Participates in classroom discussions
14. Reads aloud in class
15. Brings materials needed in the classroom
16. Responds to others with put downs
17. Uses profanity in class
18. Asks for make-up work when absent
19. Works independently
20. Refuses to accept consequences of behavior
21. Is willing to talk about inappropriate behavior
22. Visits school counselor
23. Tardy for school/class
24. Receives office discipline referrals
25. Daydreams in class
26. Communicates needs verbally
27. Communicates needs in writing
28. Defiant toward authority
29. Out of seat during class
30. Complains about being hungry
31. Has physical injuries
32. Appears happy
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Form A – Behavior Checklist
Observable Behavior
Always
Sometimes
Never
33. Appears sad/depressed
34. Uses/talks about using illegal drugs
35. Maintains good hygiene
36. Has to have the last word in spite of
consequences
37. Eats lunch in school cafeteria
38. Complains about headaches
39. Verbally abusive toward school staff
40. Physically abusive toward school staff
41. Attempts to control peers
42. Refuses to participate in class
43. Demands teacher’s attention
44. Disrupts class operations
45. Completes projects
46. Attentive in class
47. Talks at inappropriate times
48. Uses weapons
49. Other:
50. Other:
Total
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