LEARNING BEHAVIORS CHECKLIST
Tier 1 Form
Student Name:
Date:
Grade Level:
Teacher:
*Please check the behaviors impacting academic performance.*
READING
___ Does not comprehend what is read
___ Does not finish assignments due to reading
difficulty
___ Does not use word attack skills
___ Omits, adds, substitutes, or reverses letters, words,
Or sounds when reading
Additional Information:
MATHEMATICAL
CALCULATIONS/CONCEPTS
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Does not understand abstract concepts
Fails to correctly solve (+/-*) problems
Does not know/remember facts
Has difficulty solving math word problems
Additional Information:
SPEAKING
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Had difficulty imitating speech sounds
Distorts or mispronounces sounds/words
Not fluent when speaking
Does not complete thoughts when speaking
Has a limited speaking vocabulary
WRITING
___ Unable to copy letters, words, sentences, and
Numbers from a model
___ Reverses letters and Numbers
___ Does not Compose complete sentences or express
complete thoughts in writing
___ Does not organize writing activities
___ Unable to copy simple designs
Additional Information:
SPELLING
___ Has difficulty with phonetic approaches
___ Omits, substitutes, adds, or rearranges letters or
sounds when spelling
___ Requires continued drill and practice to learn
Spelling words
Additional Information:
LISTENING
___ Does not follow verbal directions
___ Has difficulty differentiating speech sounds heard
___ Requires eye contact in order to listen successfully
Additional Information:
Additional Information:
MEMORY/ORGANIZATION
ATTENTION
___ Disorganized
___ Limited memory skills VISUAL/AUDITORY
___ Requires slow, sequential, presentation of
directions/concepts
___ Inconsistent learning behaviors
___ Has difficulty staying on task
___ Doesn’t complete task before moving on to
another
___ Begins work impulsively without direction
___ Easily distracted
Additional Information:
Additional Information:
INTERPERSONAL RELATIONSHIPS
___ Has little or no interaction with teachers
MOTIVATION/EMOTIONS
___ Avoids situations, assignments, and responsibilities
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Has little or no interaction with peers
Bothers other students
Cannot work appropriately in small groups
Touches other inappropriately in small groups
Appears to always be the victim
Additional Information:
___ Ignores consequences of behavior
___ Does not appear to care about academic
performances
___ Easily agitated/hostile
___ Does not take responsibility for actions
Additional Information:
Interventions/Modifications Attempted
What strategies were tried to correct the behavior? Please indicate the date on which the strategy
was initiated and terminated, how data was gathered, and the outcome achieved by use of the
strategy.
ENVIRONMENTAL
STRATEGIES
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Preferential seating
Small group instruction
Individual instruction
Learning centers
Seating among well focused students
Provide student extra or secluded work
space
___ Other:
ORGANIZATIONAL
STRATEGIES
___ Time limits for assignments
___ Frequent questioning to help focus on
important information
___ Allowing additional time to complete
task/take test
___ Organizing a notebook or providing
folder to help organize work
___ Asking student to repeat back
Directions given
___ Highlighting main facts
___ Assignments are always posted as well
as given orally
___ Parents initial homework
___ Assignment checklist or calendar
provided for student
___ End of day clarification of homework
___ End of day clarification of homework
Not turned in
___ Other:
MOTIVATIONAL STRATEGIES
___ Sending home daily/weekly progress
reports
DATE
INITIATED
DATE
TERMINATED
HOW DATA IS
COLLECTED AND
RESULTS OF DATA
___ Immediate reinforcement of student’s
Progress
___ Keeping graphs and charts of student’s
progress
___ Conferencing with student’s parents
___ Increased parent contact (e.g. phone,
email, notes home)
___ Conferencing with student’s other
teachers
___ Student reading lesson to aide, peer
Tutor, or teacher
___ Regular feedback and progress check
Within an assignment
___ Emphasize correct answer rather than
marking incorrect answers
___ Reward system:
___ Other:
PRESENTATION STRATEGIES
___ Giving assignments/directions orally
and visually
___ Allowing oral responses when others
are giving written responses
___ Recording directions/lessons so
student can listen repeatedly
___ Immediate reinforcement of correct
response
___ Allowing student to have sample or
practice test
___ Relate topics to previous learning and
“real world”
___ Use of a scribe
___ Allow students have tests orally read
___ Other:
CURRICULUM STRATEGIES
___ Special materials (books, MP3 player,
language master, manipulatives,
calculator, computer. etc.)
___ Providing opportunities for extra drill
(Lexia, Think Central, reading series,
etc.)
___ Providing study guide (word lists,
outlines, optional projects, etc.)
___ Reducing quantity of material
___ Providing instructional materials
geared to students level of basic skills
___ Modification of assignments
___ Memory strategies
___ Other:
BEHAVIOR STRATEGIES
___ Communication between school and
home
___ Behavior system in class (e.g. positive
behavior, CHAMPS, SLANT, BEAR)
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Token system
Time-out
Affective education
Skills streaming
Five clear-cut communicated rules
Immediate consequences
Fast pace and consistent routine
Additional responsibilities
Discuss problem/solutions with
peers/grade level staff
___ Establish rapport with student
___ Student contract
___ Change student groupings, seating
___ Consult with SPED teacher/school
psychologist/other staff members
___ Private, personal cuing and signals
used with a student
___ Opportunities to work cooperatively
with another student or small group
___ Other:
ALTERNATE PROGRAM
STRATEGIES
___ Interventionist (math, reading, speech,
OT/PT)
___ One-on-one/small group assistance
from staff member
___ Title I
___ Parent volunteers
___ Conferencing with school
psychologist/school nurse
___ Community resources
___ Other:
OTHER STRATEGIES
___ 1.
___2.
NOTES:
Signature/Date