BEHAVIOR CHECKLIST Date Student Place observed Check appropriate response: ‘School Attendance Change in classroom attendance In-schoo! non-attendance Pattern of early morning tardiness Classroom tardiness Frequent schedule changes Class Performance Drop in grades/points Change in class participation Inconsistent dally work Lack of motivation; apathy Inconsistent tast of assignment grades Extracurricular Activities — Increasing noninvolvement — Not fultiting responsibilities — Los of etigiblty/dropping out Behavior - Disruptive — Datiance of rules constant discipline — Irresponsibilty, blaming, lying — Fighting/physical abuse — Cheating — Sudden outburst, verbal abuse — obscene language, gesture — Dramatic attention getting —— Extreme negativism — Hyperactivity, nervousness Person referring Grade Behavior - Unusual Talks freely about drug use Erratic behavior change as viewed on a day to day basis Change in friends Hypersensitive Inappropriate responses Depression Defensive Withdrawn, secluded, loner Seeking adult advice without a specific problem Time disorientation Change In studentteacher rapport Suicide attempt Avoidance of contact with others Forgettul Lack of motivation Talking about involvement in illegal activities Behavior: Criminal/Leaal — Selling drugs/exchanges of money — Possession of alcohol and other drugs — Involvement in thetts/assaults — Vandalism — Smoking — Canying weaponsBased on your observations, evaluate the student in comparison to other ‘students in the same grade by checking problems frequently observed. LISTENING COMPREHENSION Diffouty understanding spoken language Dificlty folowing verbal directions ORAL EXPRESSION Diffeuty expressing thoughisicess United speaking vocabulary READING Ditty with letter word recogriton ‘ord guessing Slow, constant souncing out of words Diteaty wit comprehension (lac) critical) | EXPRESSION Diticuty with speting Ditficuy wih witing speed Difficulty wih completing writen work Diicuty with punctuation Diicuty writing @ sentence Diicuty organizing sentencss and dose MATHEMATICS Ditieuty with number recognition Diffcaty with number concepts Dificuty with basic eperatons ‘acaltions ‘mutipicaton subtraction division DISCRIMINATION Ditfeuty @setiminating letter symbols Diticutycisrinating later sounds MEMORY Difficulty remembering whats soon Dificuty remembering what is heard Dificuly retaining information over a period of ime VISUAL MOTOR COORDINATION Difcuty wit sat motor asks Ditculy wih paperipenc tasks Diticuty copying om boars ATTENTION/ORGANIZATION/ACTIVITY LeveL Diicuty beginning a task Diiculy mainiinng atention Easy disvacted {Loses or forgets worWanclor materials Dilculy with organization Late for class Ditty completing tasks, Diflety wih changes in routine ‘overactive Litt SOCIAL/EMOTIONAL Uscks motivation Lacks so contra Easy trated ‘Sueden changes in mood throughout day Inconsistency in performance ‘Needs constant approval Interupis and distracts cass Unusually aggressive ward others Unusually shi or witha Dilfety making end keeping ends Doesnt accent responsibilty for own behavior] Eosllyinluenced by others Litt ttt tt SPEECH Slutors bificuty atieulating speech sounds Unusual voice quality OTHER COMMENTS:STUDENT EVALUATION From Please Return By: To: Date: Re ra: ‘Subject: Please rate the following: Excelient Good Average Poor—-Very Poor 5 4 3 2 1 Comes to class prepared Completes daily work ‘Turns in homework Test performance: Gets along with peers Classroom attitude Classroom behavior Please explain if “poor” or "very poor” and include other comments and observations, Please mark all items listed below: Subject grade (to date) ‘Absent (days) Citizenship Rating (see above) Tardy (days) COMMENTS: (Please comment on any additional factors which would help in working with this student)CHECKLIST OF SECONDARY CLASSROOM MODIFICATIONS student: Schoot: Grade: Teacher Subject: ENVIRONMENT ASSIGNMENTS INSTRUCTION/PROGRAM arty nies simpy s Alecnative Statentes | ‘change seating J shonen 4 IngumentalEnichments | reduce dtracions where J indveual contacts 4 Poses Sategios Intervention Modo! buedy syst 4 change cass assionnents —| omer 4 se of ptabooks for change groups | assinments Bite iostuction Program create more physic apace | ternative assignment conectvereecing 4 forieamer stacture 4 corectve math consir physical heath —_| extend ime 4 problems morphesraphic speling = —] se oltapercorder |] TPO * crosecage tutors “ smal groupinstvcton = — ther — mer special sty ae — ther = Leackina: ‘modiy schedule 4 TECHNIQUES sua suas Islening and netetaking = —] ad structure vary vote velimes ° 7 “oner requires 7 other 7 ' use hand on shoulder MISCELLANEOUS MATERIALS contact confor with other shoal —] use dierent matofals — — rade stilton amount fereonna . degree when appropriate pes oop work samples | teacher cruises around | a concrete rom achievement testing 7 mateias —] repeat insiucion same way —] review cum ioler | computer —]_tstassignmants andor parent contact a ingrvcions on board ‘ypowriter + ‘eleraitootce 7 use Behavior Modticaion —] _| so caleiator am selecalto— eval sin gvng atiet eontneams | inststone (overeaciocars) | sorte SST other other otter Please indicate any of the sbove which have been used.CHECKLIST OF ELEMENTARY CLASSROOM MODIFICATIONS ENVIRONMENT study carrels change seating reduce étactions where possible change class assignments change grours ‘reste more physical space forlearser consider physical health rabies cross-age tutors special suoy area oiner MATERIALS se diferent matarals tapes ‘manipulatives task carts se dagnostes materials {earring games computa stick continuums ‘ypewstor other simpy shorten ASSIGNMENTS Dat ASSIGNMENTS Continue. ingividual contacts buddy system use of notebooks for assignments atornatve assignment structure ‘extend time ud system ether TEACHING TECHNIQUES vary vine vtime a required se hand on shoulder contact ‘edu stimulation amount! gree when appropriate teacher dteuates around ‘com repeat instructions in silerent ways same way ist assignments andior Instructions on board ‘use behavior modtications se visual lds in giving intructons (overheadfooars}-— teach study sts limit number or orl inetutons Uso eye contact School: Subject: MISCELLANEOUS conter with other schol personnel keep work samples achioverent testing ‘view cum folder parent contact relorato office rateralto ‘alert SST other 180 Indicate any of the ‘above which have been used, Gircle any which has been successtulSAMPLE CONTRACT Student: David Bronwen Pareni(s); Hees. Erwan Counselor firs, Tones Math Teacher: Pe. Smith GOALS Tong term: Short term: Penalty Effective dates: Janvary 810 Tacuary 18, 1997 aE a ; a ae ee eee oe era 7 ri 5 2 From hi Responsibility Privileges (Who, What, When, How well) (Who, What, When, How much) caplned path asaiemmce eee gts nell a lecange te piclas, wer thar ery, homework acd inform Mes. gnaahs af David's progress, ae eee Who will maitorthe behavior? Fic, Smith aod tine. Teree What record will be kept? Hamewerk assignments: nvaber tucred in.acd grads ‘Who willbe responsible for the delivery of reinforcers, privileges? Hes. Smith, aff sacpus pace Signed: ‘Signed: Date: igned: Date: Dat Date: ‘This contract will be reviewed: (date) Tanwar (8Student: Pare) er rrr Counselor: Math Teachers Effective dates: 0 Goats Long term: eee Shor term: EEE Responsibility Privileges (Who, What, When, How well) (Who, What, When, Hox much) 1 ee | Bonus eee Penalty ee ‘Who will monitor the behavior? What records will be kept? ee ‘Who will be responsible for the delivery of reinforcers, privileges? Signed: Date: ____'Signed;_____Date: Signed: Date: Signed_______ pate, ‘This contrac will be reviewed: (date)SAMPLE BEHAVIOR CONTRACT Thisise Contractbemern Ace a (ame ef ten) a . The purpose ofthe Contract isto (ame ofaculysaff member) a . ee oan? . : (ame of sk) for_¢ consecutive dees ta id helshe will eam 30 oviactes soscia/ time with a thisad of her choice fe. feyralte willbe responsible fo providing this reward ‘desea person) ‘Gignaure of suet) (Gey (Sema afieachoy wey (Bisa of prea Gey ‘Cipme ofadninisoaerh = Date Contract expires: Seareavber 2 Results: Excellent = roych ie to _ eines with arene,BEHAVIOR CONTRACT This is 2 Contract between ang Teane of der ‘The purpose of the Contract is to (Wane of Rauly wal nema) eS i, ——EE—EEE——— ‘oane faa for ‘non oF ney hedshe will eam will be responsible for provi (Gesignned person) (Gnas ofsudeni) aey (iananwe oFieachay (aay ‘Benatar of paren a ‘Plz oFadaaiwaior) wy Date Contract expires: Results: ee ee, eeSAMPLE. ALTERNATIVE TO SUSPENSION BEHAVIORAL PLAN FOR INTERVENTION Student: fiarte Date: Parent: Sua ———— ‘Structured interview with parent completed Completed by whom: Zins, MentoriAdvocate identified Meeting time identified: 2200 Name Ae. Crammed orb sai ‘Summary of how student plans to contribute to school: I msi 2 ficane aach wed sda and Fridge atternaan rece, So Date plan was agreed to: 1/02/96 Summary of student's behavior contractor plan inlade strates) (fizad an have piesa ork tha counselor Sa Date plan was initiated 11/17/96 Counseling Services Summary of plan for continuing counselor support; escalate. —————— wo OOOO ‘ther agency contacts Record of incidents resulting in Alternative to Suspension: u ‘tus cB ii i rernative 1: jon = Hhday (paresALTERNATIVE TO SUSPENSION BEHAVIORAL PLAN FOR INTERVENTION Se eT er Parent: Structured interview with parent completed Completed by whom: Date: — ‘Mentor/Advocate identified Name: Meeting time identified: __ ‘Summary of how student plans to contribute to school: Date plan was agreed to: ‘Summary of student’s behavior contract or plan (include strategies): Date plan was initiated: __ Counseling or Mentoring Services ‘Summary of plan for continuing counselor oF mentor’s support: Otter agency contact Record of incidents resulting in ATS: