LAKE ZURICH HIGH SCHOOL STUDENT ASSISTANCE PROGRAM
OBSERVATION FORM
*** Please do not discuss the contents of this form with the student or others.***
Please return this form as soon as possible in an envelope to Choose your case manager:Megan BajorShaun ByrnesBarbara BelkeMichelle FerrerCraig Lehigh Merry Quinn Joanne Biondi Chasity Lansdell Michelle Levin Robert Knuth Laurie MichaelsKaye PolakoffKent StockingSheila TannerJim Yrigoyen
Date:
Student: Year:(Select Year)FreshmanSophomoreJuniorSenior
Staff Member: Subject: Hour:
Please mark on the lines provided any changes you have observed in the student. Any additional comments should be written in the comment column.
ACADEMIC PERFORMANCE ADDITIONAL COMMENTS:
1. Decline in grades
2. Decrease in thinking and problem-solving ability
3. Inattentive/ Lack of concentration/ Short attention span
4. Lack of motivation
5. Decrease in quality of work
6. Work not handed in
7. Frequent tardiness/absences
BEHAVIORS
8. Inappropriate or rude language
9. Sudden outbursts of temper
10. Frequent requests to leave the room
11. Disruptive in class
12. Other students expressing concerns
13. Withdrawn/ looks unhappy or depressed
14. Aggressive behavior
15. Frequent sharing of personal problems
16. Hypersensitive
17. Drug related talk
18. Negative change of friends
19. Mood Swings
20. Appears to have a low self-esteem
PHYSICAL INDICATORS
21. Lack of coordination (staggering or drops things)
22. Drowsiness/sleeping in class
23. Smell of alcohol or marijuana
24. Glossy or bloodshot eyes
25. Slurred of slow speech
26. Excessive nervousness/shaky
27. Excessive sniffling/runny nose
28. Noticeable weight gain or loss
29. Physical complaints
30. Lack of energy
31. Negative change in appearance or change in choice of clothes
32. Abnormal skin color
33. Hyperactivity
Complete the following:
1. If you had to assign a course grade today, based on the student's performance
continuing at its current level, course grade would be:
2. Please list any actions that you have taken in an attempt to correct the behavior (s) of concern: For example, parent contact, spoken with student, etc.
3. Are there other contacts for the SAP team that may be helpful to obtain further information about this student, such as friends, employers, coaches or others?