Appendix A
Student Survey
Name: _____________________________
Date: ______________________
1. Susie was not invited to her classmate’s birthday party over the weekend.
a. What emotion is she feeling?
b. Explain why you chose this emotion.
2. Bob got 100% on a test that he studied really hard for.
a. How is he feeling?
b. Explain why you chose this emotion.
3. Consider how you are feeling right now.
a. What emotion are you feeling?
b. Explain why you are feeling this emotion.
4. How is your body reacting to the emotion that you are feeling right now?
5. Johnny is feeling really nervous about a class presentation.
a. How might his body be reacting?
6. Judy is very angry because her parents will not let her go to the movies with her friends.
a. How might her body be reacting?
7. Consider the healthy coping strategies you use.
a. What healthy coping strategy do you often use to help yourself feel better?
b. How does your body react when you use this strategy?
(Continue writing on back)
SEEM Collaborative – DDM – School Psychologists 6-12 1
Appendix B
Student Journal Prompts
1. Think of a situation in the past two weeks when you experienced an unpleasant
emotion.
a. Describe the situation.
b. Describe the emotion you felt.
c. Describe how your feeling affected your body.
2. Think back to the coping strategy that you used to improve this situation.
a. Name the coping strategy and explain the steps that you used.
3. Explain why you chose to use this particular coping strategy.
4. Describe how the coping strategy helped.
OR If the coping strategy did not help, describe what other healthy coping strategy
you ci use if this situation happened again.
SEEM Collaborative – DDM – School Psychologists 6-12 2
Appendix C
Student Interview Checklist (for Teacher Use)
Adult Prompt
Acceptable Response
1. What is your current emotion or
feeling?
Notes:
Student labels current state with a
relevant emotion word (e.g., sad,
angry, frustrated)
If needed, first prompt: Take
another look through the emotion
cards. Is there one that shows how
you are feeling today?
2. On a scale from 1 to 5, with 1
being completely calm and 5 being
very intense and overwhelmed,
what is the intensity of the emotion
you are feeling right now?
Notes:
Student identifies intensity of
feeling on a provided scale from 1
to 5.
If needed, first prompt: Remember,
the first picture shows a calm face
because the emotion is very mild
at this end of the scale. Each
picture shows a little more intensity
to the emotion. At this end, you
would be having a very hard time
controlling your emotions because
they would feel super intense and
overwhelming. Where on the scale
would you say you are feeling right
now?
3. How is your emotion or feeling
affecting your body?
Notes:
Student links current feeling to one
or more physical symptoms that
typically occurs in concert with the
emotion identified.
Yes
Demonstrated
Independently
Yes
Demonstrated
with 1 Prompt
Yes
Demonstrated
with Multiple
Prompts
No
Did Not
Demonstrate
Despite
Prompts
No
Opportunity to
Demonstrate
Not Relevant
5
4
2
0
n/a
5
4
2
1
n/a
7
5
3
0
n/a
SEEM Collaborative – DDM – School Psychologists 19
If needed, first prompt: Think about
how the inside of your body feels
right now - your muscles, your
heart beat or pulse, your hands
and legs, your head, neck and
shoulders. Where in your body do
you feel your emotions right now?
Can you describe how your
emotions are making your body
feel?
4. Name a healthy strategy for
coping with this emotion.
Notes:
Student identifies a coping
strategy that would normally
reduce the intensity of the
identified emotion and support
productive interactions.
If needed, first prompt:
What strategies can you recall that
we have worked on together this
year? Would any of these be
helpful for coping with the emotion
you are feeling right now?
5. Review the steps and try to use
this coping strategy right now.
Notes:
Student tells the steps and applies
the coping strategy in the moment.
If needed, first prompt: What is the
very first step you need to take to
use this strategy? What do you
need to do after that? Keep going,
take me through the steps. Then
try the steps.
6. Using our scale from 1 to 5,
what is the intensity of the emotion
or feeling now? (If the emotion is
not calmed down yet, ask, “What
Student indicates that the intensity
of the emotion has decreased and,
if needed, describes steps that
could further reduce the intensity
9
6
3
0
n/a
9
6
3
0
n/a
9
6
3
0
n/a
SEEM Collaborative – DDM – School Psychologists
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could help to further reduce the
intensity of the emotion?”)
Notes:
of the felt emotion.
If needed, first prompt: Remember,
the first picture shows a calm face
because the emotion is very mild
at this end of the scale. Each
picture shows a little more intensity
to the emotion. At this end, you
would be having a very hard time
controlling your emotions because
they would feel super intense and
overwhelming. Where on the scale
would you say you are feeling right
now?
TOTAL SCORE
Special Accommodations Provided:
/ 44
Rationale for Accommodations Provided:
SEEM Collaborative – DDM – School Psychologists
21
Appendix D
Student Survey Scoring Guide (For Teacher Use)
Fully Correct Responses:
- Answers all parts of the question and - Provides relevant and plausible responses for all parts
Partially Correct Responses: - Answers some parts of the question or - Answers all parts, but not always relevant or plausible responses
Not Correct Responses:
- Answers are incomplete
and/or - Answers are not relevant or plausible
Student Name:
#
1
2
3
4
5
6
7
Question
Date:
Guidance
Susie was not invited to her classmate’s
birthday party over the weekend.
- What emotion is she feeling?
- Explain why you chose this emotion.
Student identifies how he/she
might feel and explains why this
feeling might be likely after being
left out of event by a peer
Bob got 100% on a test that he studied
really hard for.
- How is he feeling?
- Explain why you chose this emotion.
Student identifies a positive
feeling related to
accomplishment
Consider how you are feeling right now.
- What emotion are you feeling?
- Explain why you are feeling this emotion.
Student names an actual feeling
or emotion, rather than a
description, an example, a wish,
or other response
Student describes feeling in the
body that connects with the
listed emotion
Student describes a feeling
related to an undesired activity
How is your body reacting to the emotion
that you are feeling right now?
Johnny is feeling really nervous about a
class presentation.
- How might his body be reacting?
Judy is very angry bc her parents will not let
her go to the movies with her friends.
- How might her body be reacting?
Consider healthy coping strategies you use.
- What healthy coping strategy do you often
use to help yourself feel better?
- How does your body react when you use
this strategy?
Special Accommodations Provided:
Examples of Correct
Responses
Sad, mad, lonely
Susie would probably feel angry
because it is not kind to leave
friends out of a special event.
Proud, excited, happy
Bob would feel proud because
he probably studied really hard
to get every question right.
Fully
Correct
Partially
Correct
Not
Correct
5
2
0
5
2
0
5
2
0
7
3
0
7
3
0
Angry, frustrated, sad
Angry: Trembling, pit in stomach
Sad: Lack of energy
Tense: I have a headache
Sweating, racing heart, stomach
ache
Student describes physical
symptoms related to anger
Tense, hot, pit in stomach,
verbal outburst, shaking
7
3
0
Student identifies a healthy,
productive coping strategy and
describes how his/her body
reacts in response
Go for walk: calms my mood
Breathe deeply: relax muscles
Count to 100: distracts me
8
4
0
TOTAL SCORE
Rationale for Accommodations Provided
/44
SEEM Collaborative – DDM – School Psychologists 22
Appendix E
Journal Prompts Scoring Guide (For Teacher Use)
Fully Correct Responses:
- Answers all parts of the question and - Provides relevant and plausible responses for all parts
Partially Correct Responses: - Answers some parts of the question or - Answers all parts, but not always relevant or plausible responses
Not Correct Responses:
- Answers are incomplete
and/or - Answers are not relevant or plausible
Student Name:
Item
#
Date:
Question
Prompt: Think of a time in the past two
weeks when you experienced an
unpleasant feeling or emotion.
a. Describe the situation.
b. Describe the emotion you felt.
1
c. Describe how your feeling
affected your body.
2
Prompt: Think back to the coping
strategy that you used to improve this
situation
a. Name a coping strategy and the
steps that you used.
Guidance
Examples of Correct
Responses
Acceptable?
Fully
Correct
Partially
Correct
Not
Correct
.
Student describes an unpleasant
situation and what happened.
Student correctly identifies an emotion
using an emotion word rather than a
description of what the emotion was
“like” or what the student wanted to do
in response to the emotion.
Student links feelings with physical
state, suggesting connection between
emotion and muscles, sweat or tear
glands, tensions (headache, neck or
shoulder cramps, jittery hands or
legs), heart rate, pulse, or energy
level, etc.
Student correctly names a taught
coping strategy and explains a correct
and complete sequence of steps to
Student identified an unpleasant
experience within the academic,
social, and/or personal realm.
Sad, Anxious, Angry, Jealous,
Depressed, Furious, Confused
5
5
Lack of energy (sad)
Sweaty palms, racing heart
(anxious, nervous)
Tense, hot, pit in stomach
(angry, mad)
Deep breathing.
Be aware of my breathing.
2
2
0
0
6
3
0
9
4
0
SEEM Collaborative – DDM – School Psychologists
23
3
4
implement it.
2. Slow down my breathing.
3. Breathe more deeply and
longer.
4. Feel my heart beat.
Prompt: Explain why you chose to
use this particular coping strategy.
Student explains at least one
plausible reason for choosing a
specific strategy.
I felt my heart begin to race so I
tried to slow my breathing down
and take deeper breaths.
Prompt: Describe how the coping
strategy helped.
Student describes how the coping
strategy helped to address the
negative emotion and situation.
Felt calmer so didn’t react
strongly or immediately to the
other person and was able to
walk away or respond calmly.
Prompt: OR if the coping strategy did
not help, describe what other healthy
coping strategy you could use if this
situation happened again.
Student identifies how the strategy
failed to improve current emotional
state and also identifies an alternative
healthy coping strategy to use for the
future.
Next time, try to pay attention to
the triggers that are upsetting
me, such as the person’s use of
blaming language.
Total
Special Accommodations Provided:
9
4
0
9
4
0
9
4
0
/52
Rationale for Accommodations Provided:
SEEM Collaborative – DDM – School Psychologists
24
Appendix F
Scoring Tracking Sheet
Student: ______________________
Journal
Prompts
Interview
Checklist
Subtotal
Student
Survey
Total
Sept
Oct
Nov
Dec
Jan
Feb
March
April
May
Date:
/52
Date:
/52
Date:
/52
Date:
/52
Date:
/52
Date:
/52
Date:
/52
Date:
/52
Date:
/52
/44
/44
/44
/44
/44
/44
/44
/44
/44
/96
/44
/96
/96
/96
/96
/96
/96
/96
/96
/44
/140
Gain
Date:
/140
Example
Journal
Prompts
Interview
Checklist
Subtotal
Student
Survey
Overall
Total
Sept
Oct
Nov
Dec
Jan
Feb
March
April
May
Date:
7/52
Date:
13/52
Date:
13/52
Date:
17/52
Date:
26/52
Date:
17/52
Date:
35/52
Date:
41/52
Date:
41/52
Gain
Date
+34 pts
10/44
10/44
17/44
10/44
17/44
26/44
26/44
35 /44
44/44
+34 pts
17/96
16/44
23/96
30/96
27/96
43/96
43/96
61/96
76/96
85/96
32 /44
+68/96
+16 pts
117/140 +84/140
points
33/140
This student’s overall gain for the year +84 points.
SEEM Collaborative – DDM – School Psychologists 25