For how many months have you known this pupil?
How well do you know him/ her?
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?
What kind and when?
Does this pupil have any illness or disability (either physical or mental)?
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)
Add academic subjects and rate pupil's performance for each subject
How would you rate pupil's performance?
Compared to typical pupils of the same age:
How hard is he/ she working?
How appropriately is he/ she behaving?
How much is he/ she learning?
How happy is he/ she?
Acts too young for his/ her age
Drinks alcohol without parents' approval
Argues a lot
Fails to finish things he/ she starts
There are very little or a few things that he/ she enjoys
Bowel movements outside toilet
Trouble concentrating or can't pay attention for a longer time
Trouble getting his/ her mind off certain thoughts; obsessions
Can't sit still, restless or hyperactive
Clings to adults or too dependent
Complains of loneliness
Confused or seems to be in a fog
Cries a lot
Cruel to animals
Cruelty, bullying or mean to others
Daydreams or gets lost in his/ her own thoughts
Deliberately harms self or attempts suicide
Demands a lot of attention
Destroys his/ her or others things on purpose
Doesn't eat well
Defiant to rules at home, school or elsewhere
Doesn't socialize well with other kids
Doesn't feel any guilt after misbehaving
Fears certain animals, situations or places other than school
Fells or complains that no one loves him/ her
Gets into many fights
Gets teased a lot
Hangs around people who are a bad influence
Hears sound or voices that aren't there
Impulsive or acts without thinking
Lying or cheating
Nervous movements or twitching
Nightmares or Night terrors
Too fearful or anxious
Feels too guilty
Overtired without good reason
Physical problems without known medical cause
Aches or pains (not stomach or headaches)
Nausea or feels sick
Problems with eyes (not if corrected by glasses)
Rashes or other skin problems
Vomiting or throwing up
Others that were not mentioned