Teacher Survey

Teacher Survey

OMB Number: Exp Date:

PLEASE COMPLETE THE FOLLOWING:

Student Name: Remove label before returning form.

Grade of Student: O Pre-K O K O 1st O 2nd O 3rd O 4th O 5th O 6th O 7th O 8th O 9th O 10th O 11th O 12th

I D #:

Each rating should be considered in the context of what is appropriate for the age of the child you are rating and should reflect that child’s behavior since the beginning of the school year. Please, (1) fill in only one bubble (answer) per question, (2) use a #2 pencil or black pen to complete the form, and (3) do not write or place any stray marks on the form except where specified.

BEHAVIOR:

Never

Occasionally

Often

Very Often

1. Fails to give attention to details or makes careless mistakes in schoolwork.

O

O

O

O

2. Has difficulty sustaining attention to tasks or activities.

O

O

O

O

3. Does not seem to listen when spoken to directly.

O

O

O

O

4. Does not follow through on instructions and fails to finish schoolwork (not due to oppositional behavior or failure to understand).

O

O

O

O

5. Has difficulty organizing tasks and activities.

O

O

O

O

6. Avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort.

O

O

O

O

7. Loses things necessary for tasks or activities (school assignments, pencils, or books).

O

O

O

O

8. Is easily distracted by extraneous stimuli.

O

O

O

O

9. Is forgetful in daily activities.

O

O

O

O

10. Fidgets with hands or feet or squirms in seat.

O

O

O

O

11. Leaves seat in classroom or in other situations in which remaining seated is expected.

O

O

O

O

12. Runs about or climbs excessively in situations in which remaining seated is expected.

O

O

O

O

13. Has difficulty playing or engaging in leisure activities quietly.

O

O

O

O

14. Is “on the go” or often acts as if “driven by a motor.”

O

O

O

O

15. Talks excessively.

O

O

O

O

16. Blurts out answers before questions have been completed.

O

O

O

O

17. Has difficulty waiting in line.

O

O

O

O

18. Interrupts or intrudes on others (e.g., butts into conversations or games).

O

O

O

O

19. Loses temper.

O

O

O

O

20. Actively defies or refuses to comply with adult’s requests or rules.

O

O

O

O

21. Is angry or resentful.

O

O

O

O

22. Is spiteful and vindictive.

O

O

O

O

23. Bullies, threatens, or intimidates others.

O

O

O

O

24. Initiates physical fights.

O

O

O

O

25. Lies to obtain goods or favors or to avoid obligations (i.e., “cons” others).

O

O

O

O

26. Is physically cruel to people.

O

O

O

O

Public reporting burden of this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Clearance Officer; 1600 Clifton Road NE, MS D-24, Atlanta, Georgia 30333; ATTN: PRA (0920-xxxx).

Never

Occasionally

Often

Very Often

27. Has stolen items of nontrivial value.

O

O

O

O

28. Deliberately destroys others’ property.

O

O

O

O

29. Is fearful, anxious, or worried.

O

O

O

O

30. Is self-conscious or easily embarrassed.

O

O

O

O

31. Is afraid to try new things for fear of making mistakes.

O

O

O

O

32. Feels worthless or inferior.

O

O

O

O

33. Blames self for problems, feels guilty.

O

O

O

O

34. Feels lonely, unwanted, or unloved; complains that “no one loves him/her”.

O

O

O

O

35. Is sad, unhappy, or depressed.

O

O

O

O

PERFORMANCE:

Academic Performance

Problematic

Average

Above Average

Reading

O

O

O

O

O

Mathematics

O

O

O

O

O

Written Expression

O

O

O

O

O

Classroom Behavioral Performance

Problematic

Average

Above Average

Relationship with peers

O

O

O

O

O

Following directions

O

O

O

O

O

Disrupting class

O

O

O

O

O

Assignment completion

O

O

O

O

O

Organizational skills

O

O

O

O

O

Impairment and Burden

1. Overall, do you think that this child has difficulties in any of the following areas: emotions, concentration, behavior or being able to get along with other people?

No O

Yes - minor difficulties O

Yes - definite difficulties O

Yes – severe difficulties O

2. If yes, what type of burden have the difficulties caused:

Not at all

A little

A medium amount

A great deal

Put a burden on you or the class as a whole

O

O

O

O

Disrupting class

O

O

O

O

Interfering with other students

O

O

O

O

Time spent getting his/her attention

O

O

O

O

Time spent getting him/her to settle down or sit still

O

O

O

O

Having to devote extra attention to him/her to protect him/her or classmates from impulsive actions

O

O

O

O

3. Do the difficulties interfere with the child's everyday life in the following areas?

Peer relationships

O

O

O

O

Classroom learning

O

O

O

O

Critical Events: Answer the following questions about THIS school year.

How many days was this child absent from school?

Total Number:

How many different times was this student in detention?

Total Number:

Why?

Behavioral O

Academic O

Other O

Don’t Know O

How many different times was this student suspended or received in-school suspension?

Total Number:

Why?

Behavioral O

Academic O

Other O

Don’t Know O

How many different times was this student expelled?

Total Number:

Why?

Behavioral O

Academic O

Other O

Don’t Know O

Does this child have a 504 Plan for this school year?

YES O

NO O

Don’t Know O

Why?

Behavioral O

Academic O

Other O

Don’t Know O

Does this child have an IEP Plan for this school year?

YES O

NO O

Don’t Know O

Why?

Behavioral O

Academic O

Other O

Don’t Know O

Is this child in any resource or special education classes this school year?

YES O

NO O

Don’t Know O

Type:

Behavioral O

Academic O

Other O

Don’t Know O

Do you consider this child an:

A student O

B student O

C student O

D student O

F student O

Don’t Know O