Confidential: All information must be specific, descriptive, observable, and factual

MIDDLE SCHOOL

TEACHER DATA COLLECTION FORM

NOTE: This form should be completed and returned in a sealed envelope to the Student

Assistance Team in-box (located in the Principal’s Office), safeguarding the

confidentiality of the student.

Student:______Grade:______

Date of Birth:______Days Absent to Date:______

Teacher:______Date:______

Please return by:

****Please attach a copy of the current report card.****

Current Academic Levels/Grades / Strengths / Weaknesses
Reading/Lang. Arts
Math
Language
Social Studies
Science
Expressive Arts
Other:

Directions: If you have observed the behavior or action, please place a check before the statement. (Remember, any behavior must be observed)

Classroom Performance
oFailed one or more subject areas -- List
/ oDoes not complete in-class assignments
( %)
oHomework is sloppy or incomplete
(attach example) / oPoor short term memory (i.e., cannot remember one day to next)
oNeeds directions given individually / oShort attention span, easily distracted
oDecrease in class participation / oDrop in grades, lower achievement
oDoes not ask for help / oPrefers to work alone
oFails to complete homework ( %) / oGives up easily
oHas ability, but does not apply self

Confidential: All information must be specific, descriptive, observable, and factual

Social Skills
oAppears to be a loner / oResents authority (attitude)
oLacks peer relationships / oHas to be center of attention
oDisrespectful of authority / oFrequent ridicule from classmates
oDisturbs other students / oAppears unhappy/sad
oLacks self-confidence / oAngered by any criticism
oTeases other students / oLacks control in unstructured situations
oNegative leader / oChange in friends
oArgues with teacher / oSexual behavior in public
oHits and/or pushes other students / oWithdrawn, difficulty in relating to others
oTalks freely about drugs / oMakes inappropriate remarks
Disruptive Behavior
oDefiance of rules / oObscene language, gestures
oIrresponsibility, blaming, denying / oNoisy, boisterous
oFighting / oCrying
oCheating / oHighly active
oSudden outbursts of anger; verbally abusive to others / oErratic behavior/mood swings

If you have checked any item in the above area, please EXPLAIN in detail below remembering all information/comments must be specific, descriptive, observable, and factual.

Physical Symptoms
o Underweight / o Frequent physical injuries
o Overweight / o Deteriorating personal appearance
o Smells of smoke, alcohol, marijuana / o Sleeps in class
o Comes to school inappropriately dressed / o Glassy, bloodshot eyes
o Tense, seems on edge / o Poor hygiene
o Slurs speech / o Frequent requests to see the nurse
o Appears sleepy, lethargic / oFrequent complaints of nausea/headaches
Background Information (If documented)
o Attendance problems (attach report)
oSingle parent household
oDeath in immediate family
Who?
oDivorce or separation / oKnown medical problems
oChild discusses concern regarding drug and alcohol use in the home
oTakes medication
oPreviously involved with counseling
oUnemployment / oCurrently involved with counseling
oLives with someone other than parent
Who? / oPreviously referred/retained
Related Services
School Based: / Community/Agency Based:
o AIS for what areas? / o List if documented
oSchool Counselor (Counseling) / o
o
o Speech and Language / o
o OT/PT / o
o Other Specialists / o
o /
What do you see as the student’s STRENGTHS; including life skills, assets, resources, interests, and talents?