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Download Behavior Checklist for all Teachers of SAT
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Behavior Checklist for all Teachers of SAT-Referred Students Student______________________________________ #___________________ Grade________________ Check only those behaviors you have personally observed. Return to (504 Coordinator) by ______________. Date Academic Performance ____ Significant change in grades ____ Academic failure ____ Lack of motivation—apathy School Attendance ____ Frequent absenteeism (excused or not) ____ Frequent tardiness ____ Frequent counselor visits ____ Frequent nurse visits ____ Frequent schedule changes ____ Suspension from school and/or class Extracurricular Activities ____ Loss of eligibility ____ Increasing non-involvement ____ Dropped out ____ Ignores activity rules Physical Symptoms ____ Poor hygiene ____ Smelling of alcohol, smoke or marijuana ____ Vomiting ____ Glassy, bloodshot eyes ____ Coordination problems ____ Slurred speech ____ Changes in appearance ____ Noticeable weight gain or loss ____ Shakiness ____ Listless—drowsy ____ Physical injuries Behavior—Disruptive ____ Defiance of rules—constant discipline ____ Irresponsibility, blaming, denying, lying ____ Fighting ____ Cheating ____ Sudden outbursts—verbal abuse ____ Obscene language—gestures ____ Dramatic attention getting ____ Frequent need to leave classroom ____ Extreme negativism ____ Hyperactivity, nervousness Indicate below any interventions tried before SAT referral (E=effective, I=ineffective): ____ Behavior Management ____ Conference with parent ____ Conference with student ____ Conference with resource personnel If so, who? __________________ ____ Sent note home ____ Called home ____ Kept student before/after school ____ Positive reinforcement ___verbal ___written ____ Modified assignments ____ Other Teacher__________________________ Subject___________________________ Grade at present___________________ Behavior-Atypical ____ Talks freely about drug/alcohol use ____ Erratic behavior—mood swings ____ Paranoid (feels persecuted, picked on) ____ Change of friends—usually negative ____ Alibi, elaborate excuses ____ Excessive crying ____ Time disorientation ____ Inappropriate responses ____ Defensive ____ Unusual eating behaviors ____ Promiscuity ____ Withdrawn, secluded, loner ____ Job problems ____ Displays of inappropriate affection with peers Behavior—Criminal—Legal ____ Selling drugs—exchange of money ____ Possession of drugs and paraphernalia ____ Vandalism ____ Smoking or chewing ____ Alcohol or drug use ____ Bringing alcohol/drugs to school ____ Carrying weapons Home Problems ____ Run away ____ Speaks angrily of parents ____ Unusual sibling problems ____ Suffered recent loss (move, divorce, death, etc.) ____ Troubles in family (health, financial, emotional) ____ Other areas (please specify) _______________ Check all behaviors that apply: ____ Short attention span ____ Difficulty concentrating ____ Disturbs other students ____ Doesn’t respect the property of others and/or self ____ Difficulty following instructions __verbal __written ____ Low frustration level ____ Sad ____ Excitable ____ Oversensitive ____ Destructive ____ Disruptive ____ Aggressive ____ Withdrawn ____ Quarrelsome ____ Disorganized ____ Selfish ____ Day dreams ____ Overly serious ____ Temper outbursts Attitude toward authority: ____ Excessive demands for teacher attention ____ Overly anxious to please ____ Submissive ____ Cooperative ____ Stubborn ____ Rude ____ Defiant ____ Fearful What were the parents’ reactions to hearing about your concerns (attach any documentation from parents)? Use the back of this paper to answer.
