Date: # of Observation Sheets sent out:
Student: # of Observation Sheets returned:
Year:
Case Manager:
Instructions: Fill in the total # of responses in front of each
question. Sum up "additional comments" at the end of the form.
ACAEMIC PERFORMANCE
1. Decline in grades 13. Withdrawn/ looks unhappy or depressed
2. Decrease in thinking and problem-solving ability. 14. Aggressive behavior
3. Inattentive/ Lack of concentration/ Short attention span 15. Frequent sharing of personal problems
4. Lack of motivation 16. Hypersensitive
5. Decrease in quality of work 17. Drug related talk
6. Work not handed in 18. Negative change of friends
7. Frequent tardiness/ absences 19. Mood swings
20. Appears to have low self-esteem
BEHAVIORS
8. Inappropriate or rude language PHYSICAL INDICATORS
9. Sudden outbursts of temper 21. Lack of coordination (staggering or drops things)
10. Frequent request to leave the room 22. Drowsiness/ sleeping in class
11..Disruptive in class 23. Smell of alcohol or marijuana
12. Other students expressing concerns
24. Glossy or bloodshot eyes
26. Excessive nervousness/shaky 30. Lack of energy
27. Excessive sniffling/runny nose
31. Negative change in appearance or change
in choice of clothes
28. Noticeable weight gain or loss
32. Abnormal skin color
29. Physical complaints
33. Hyperactivity
Summary of teacher comments.
1. Summary of grades if assigned today: period 1
period 6
period 2
period 7
period 3
period 8
period 4
period 9
period 5
2. Summary of teachers' actions taken to correct behaviors(s)
of concern.
3. Summary of teachers' comments regarding other contacts for
the SAP team that may be helpful.