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Teacher Name
First Name
Last Name
Student Name
First Name
Last Name
Student Grade
PK
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1st
2nd
3rd
4th
5th
Student Age
Which Apply to Student
Special Education Student
ESOL
EIP
RTI
TAG
Speech and Language
Diagnosed ADHD
Internalizing Behaviors
Exhibits sadness or depression
Teased or bullied by peers
Sleeping
Does not stand up for self
Doesn't participate
Self-injury
Acts fearful
Withdrawn/isolated
Externalizing Behaviors
Out of seat/assigned area
Defiance
Inappropriate language
Talking out of turn
Eloping
Chronic absenteeism/tardies
Frequent illness/ trips to nurse
Fighting/physical agression
Strategies Used
Successful
Somewhat Successful
Unsuccessful
Reteaching of behaviors
2
3
4
Tangible recognition for expected behaviors
5
6
7
Multiple opportunities to practice
8
9
10
Self-monitoring
11
12
13
4:1 positive feedback
14
15
16
Relaxation/coping techniques
17
18
19
Modified assignments
20
21
22
Counselor assistance
23
24
25
Parent/guardian contact
26
27
28
Scheduled breaks
29
30
31
Additional Strategies not Listed in Table
Traumatic Event
Parent Communication
Additional Information
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