Teacher's Report Form

• Name of School

• Pupil 's name

• Grade Level

• Gender

• Age

• Pupil's birthdate

  Date

• Form filled out by

• Your role at the school

  Select Classroom Teacher Special Educator Counselor Administrator Teacher's Aide Others

  • Classroom Teacher
  • Special Educator
  • Counselor
  • Administrator
  • Teacher's Aide
  • Others

• Please specify

• Date Conducted

  Date

General Information

• For how many months have you known this pupil?

• How well do you know him/ her?

  Well

  Moderately Well

  Very Well

• How much time does he/ she spend in your class per week?

• What class of yours is he/ she in? (i.e regular 5th grade, 7th grade math, counseling, learning disability etc)

• Has he/ she ever been referred for special class placement, services, or tutoring?

  Yes

  No

  N/A

• What kind and when?

• Does this pupil have any illness or disability (either physical or mental)?

  No

  Yes

  N/A

• Please describe

• What concerns you most about this pupil?

• Please describe the best things about this pupil (feel free to write any comments about the pupil's work, behavior, or potential)

Academic Performance

• Add academic subjects and rate pupil's performance for each subject

Subject

• Subject

• How would you rate pupil's performance?

  Failing

  Below Average

  Average

  Above Average

Academic Behavior

• Compared to typical pupils of the same age:

• How hard is he/ she working?

  Less than average

  Average

  More than average

  Don't know

• How appropriately is he/ she behaving?

  Less than average

  Average

  More than average

  Don't know

• How much is he/ she learning?

  Less than average

  Average

  More than average

  Don't know

• How happy is he/ she?

  Less than average

  Average

  More than average

  Don't know

General Behavior

• Acts too young for his/ her age

  Not True

  Somewhat True

  Very True

• Drinks alcohol without parents' approval

  Not True

  Somewhat True

  Very True

• Argues a lot

  Not True

  Somewhat True

  Very True

• Fails to finish things he/ she starts

  Not True

  Somewhat True

  Very True

• There are very little or a few things that he/ she enjoys

  Not True

  Somewhat True

  Very True

• Bowel movements outside toilet

  Not True

  Somewhat True

  Very True

• Bragging, boasting

  Not True

  Somewhat True

  Very True

• Trouble concentrating or can't pay attention for a longer time

  Not True

  Somewhat True

  Very True

• Trouble getting his/ her mind off certain thoughts; obsessions

  Not True

  Somewhat True

  Very True

• Can't sit still, restless or hyperactive

  Not True

  Somewhat True

  Very True

• Clings to adults or too dependent

  Not True

  Somewhat True

  Very True

• Complains of loneliness

  Not True

  Somewhat True

  Very True

• Confused or seems to be in a fog

  Not True

  Somewhat True

  Very True

• Cries a lot

  Not True

  Somewhat True

  Very True

• Cruel to animals

  Not True

  Somewhat True

  Very True

• Cruelty, bullying or mean to others

  Not True

  Somewhat True

  Very True

• Daydreams or gets lost in his/ her own thoughts

  Not True

  Somewhat True

  Very True

• Deliberately harms self or attempts suicide

  Not True

  Somewhat True

  Very True

• Demands a lot of attention

  Not True

  Somewhat True

  Very True

• Destroys his/ her or others things on purpose

  Not True

  Somewhat True

  Very True

• Doesn't eat well

  Not True

  Somewhat True

  Very True

• Defiant to rules at home, school or elsewhere

  Not True

  Somewhat True

  Very True

• Doesn't socialize well with other kids

  Not True

  Somewhat True

  Very True

• Doesn't feel any guilt after misbehaving

  Not True

  Somewhat True

  Very True

• Easily jealous

  Not True

  Somewhat True

  Very True

• Fears certain animals, situations or places other than school

  Not True

  Somewhat True

  Very True

• Self-conscious

  Not True

  Somewhat True

  Very True

• Perfectionist

  Not True

  Somewhat True

  Very True

• Feels worthless

  Not True

  Somewhat True

  Very True

• Fells or complains that no one loves him/ her

  Not True

  Somewhat True

  Very True

• Accident prone

  Not True

  Somewhat True

  Very True

• Gets into many fights

  Not True

  Somewhat True

  Very True

• Gets teased a lot

  Not True

  Somewhat True

  Very True

• Hangs around people who are a bad influence

  Not True

  Somewhat True

  Very True

• Hears sound or voices that aren't there

  Not True

  Somewhat True

  Very True

• Impulsive or acts without thinking

  Not True

  Somewhat True

  Very True

• Lying or cheating

  Not True

  Somewhat True

  Very True

• Nervous movements or twitching

  Not True

  Somewhat True

  Very True

• Nightmares or Night terrors

  Not True

  Somewhat True

  Very True

• Constipated

  Not True

  Somewhat True

  Very True

• Too fearful or anxious

  Not True

  Somewhat True

  Very True

• Feels too guilty

  Not True

  Somewhat True

  Very True

• Overeating

  Not True

  Somewhat True

  Very True

• Overtired without good reason

  Not True

  Somewhat True

  Very True

• Overweight

  Not True

  Somewhat True

  Very True

• Physical problems without known medical cause

  Not True

  Somewhat True

  Very True

• Aches or pains (not stomach or headaches)

  Not True

  Somewhat True

  Very True

• headaches

  Not True

  Somewhat True

  Very True

• Nausea or feels sick

  Not True

  Somewhat True

  Very True

• Problems with eyes (not if corrected by glasses)

  Not True

  Somewhat True

  Very True

• Rashes or other skin problems

  Not True

  Somewhat True

  Very True

• Stomachaches

  Not True

  Somewhat True

  Very True

• Vomiting or throwing up

  Not True

  Somewhat True

  Very True

• Others that were not mentioned

Behavior

• Name behavior

• Rate behavior

  Worse

  Average

  Better

Completion

• Name & Signature of Teacher

  Sign